DR.   D.  C.    FARNHAM 

AND 

DR.   MARGARET    H.   FARNHAM 

OSTEOPATHIC     PHYSICIANS 


COLLEGE  OF  OSTEOPATHIC   PHYSICIANS 
AND  SURGEONS  •  LOS  ANGELES,  CALIFORNIA 


THE 


TSEXUAL  LIFE  OF  WOMAN 

• — 1 


IN  ITS 


PHYSIOLOGICAL,    PATHOLOGICAL 
AND   HYGIENIC   ASPECTS 


V 

BY/ 

<£  4' 

E.  HEINRICH  KISCH,  M.  D. 

Professor  of  the  German  Medical  Faculty  of  the  University  of  Prague  ;  Physician  to 
the  Hospital  and  Spa  of  Marienbad  ;  Member  of  the  Board  of  Health,  Etc.,  Etc. 


ONLY  AUTHORIZED  TRANSLATION  INTO  THE  ENGLISH  LANGUAGE   FROM 
THE  GERMAN  BY 

M.  EDEN  PAUL,  M.  D. 


WITH  97  ILLUSTRATIONS  IN  THE  TEXT 


NEW  YORK 

REBMAN  COMPANY 

1123  BROADWAY 


Lofico 

£J'$ 

V31P 


COPYRIGHT,  1910,  BY 
REBMAN  CO.,  NEW  YORK 


ALL  RIGHTS  RESEBVED 


Printed  in   America 


TO  MY  ONLY  SON 

FRANZ  KISCH,  M.  D. 

AS  A  TOKEN  OF  PATERNAL  AFFECTION 

I  DEDICATE  THIS  BOOK 


PREFACE. 


The  sexual  life  of  woman  —  the  appearance  of  the  first  indica- 
tions of  sexual  activity,  the  development  of  that  activity  and  its 
culmination  in  sexual  maturity,  the  decline  of  that  activity  and  its 
ultimate  extinction  in  sexual  death  —  the  entire  process  of  the  most 
perfect  work  of  natural  creation  —  has  throughout  all  ages  kindled 
the  inspiration  of  poets,  aroused  the  enthusiasm  of  artists,  and  sup- 
plied thinkers  with  inexhaustible  material  for  reflection. 

In  the  following  pages,  this  sexual  life  of  woman  will  be  con- 
sidered both  in  relation  to  the  female  genital  organs,  and  in  relation 
to  the  feminine  organism  as  a  whole ;  in  relation  both  to  the  physical 
and  to  the  mental  development  of  the  individual;  and  in  relation 
alike  to  the  state  of  health  and  to  the  processes  of  disease.  Thus 
from  the  standpoint  of  clinical  investigation  and  of  practical  experi- 
ence, the  book  will  be  a  contribution  towards  the  solution  of  the 
sexual  problem,  nowadays  recognized  as  one  of  supreme  importance. 

It  is  thirty  years  since  I  published  a  work  on  the  histological 
changes  that  occur  in  the  ovaries  during  the  climacteric  period 
(Archiv.  fur  Gynecologic,  Vol.  xii,  Section  3)  ;  and  ever  since  that 
time,  the  influence  exerted  upon  the  general  health  of  women  by  the 
physiological  and  pathological  processes  occurring  in  their  repro- 
ductive organs,  has  been  to  me  a  favourite  subject  for  observation 
and  experiment.  The  result  of  these  studies  is  incorporated  in  my 
monographs,  "  The  Climacteric  Period  in  Women "  ( Erlangen, 
1874),  "Sterility  in  Women"  (2nd  Ed.,  Vienna,  1895),  "The 
Uterus  and  the  Heart"  (Leipzig,  1898),  and  in  various  contributions 
to  medical  periodicals.  I  now  have  a  welcome  opportunity  of  draw- 
ing a  general  picture  of  sexual  activity  in  women,  and  of  illuminating 
this  picture  both  by  the  light  of  my  own  experience  and  by  numerous 
references  to  the  works  of  other  authors.  In  passing,  I  have  de- 
voted considerable  attention  to  questions  of  education  and  per- 
sonal hygiene,  both  of  which  are  greatly  influenced  by  the  processes 
of  the  sexual  -life.  Thus,  I  hope,  the  work  will  be  rendered  more 
interesting  to  the  physician,  and  the  general  picture  it  is  intended  to 
convey  will  be  more  fully  characterized  by  contemporary  actuality. 

Natural  divisions  of  the  subject  are,  I  consider,  furnished  by  the 
three  great  landmarks  of  the  sexual  life  of  woman :  the  onset  of 
menstruation  —  the  menarche:  the  culmination  of  sexual  activity  — 


yi  PBEFAC& 

the  menacme;  and  the  cessation  of  menstruation  —  the  menopause. 
These  several  sexual  epochs  are  differentiated  by  characteristic 
anatomical  states  of  the  reproductive  organs,  by  the  external  con- 
figuration of  the  feminine  body,  by  functional  effects  throughout 
the  entire  organism,  and,  finally,  by  pathological  disturbances  of 
the  normal  vital  processes. 

Thus  in  separate  chapters  a  description  is  given  of  sexual  proc- 
esses, a  detailed  exposition  of  which  will  be  vainly  sought  in  the 
textbooks  of  gynecology,  yet  which  are  none  the  less  of  far-reaching 
importance  in  relation  to  the  physical,  mental,  and  social  well-being 
of  women,  and  in  relation  also  to  the  development  of  human  society; 
such  topics  are,  the  sexual  impulse,  copulation,  fertility,  sterility,  the 
employment  of  means  for  the  prevention  of  conception,  the  determi- 
nation of  sex,  sexual  hygiene.  To  the  topics  of  pregnancy,  parturi- 
tion, lying-in,  and  lactation,  since  these  are  adequately  discussed  in 
works  on  midwifery,  but  little  space  has  here  been  allotted. 

It  is  my  earnest  hope  that  physicians  and  biologists  may  derive 
benefit  from  the  book  equal  in  amount  to  the  pleasure  I  have  gained 
in  the  work  of  writing  it. 

E.  HEINRICH  KISCH. 


1ABLE   OF  CONTENTS. 


PAGH 

THE  SEX JAL  LIFE  OF  WOMAN  —  Introduction i 

T.  THE  SEXUAL  EPOCH  OF  THE  MENARCHE 37 

First  Appearance  of  Menstruation 45 

Anatomical  Changes  in  the  Female  Genital  Organs  at  the  Period 
of  the  Menarche 50 

Menarche  Praecox  et  Tardiva 78 

Precocious  and  Retarded  Menstrual  Activity 78 

Pathology  of  the  Menarche 82 

Anomalies  of  Menstruation 83 

Inflammatory  Processes 87 

Disorders  of  Haematopoiesis 89 

Cardiac  Disorders 94 

Diseases  of  the  Nervous  System 99 

Masturbation 104 

Disorders  of  Digestion 107 

Diseases  of  the  Respiratory  Organs 107 

Diseases  of  the  Organs  of  the  Senses 108 

Hygiene  during  the  Menarche in 

Menstruation 128 

Pathology  of  Menstruation 143 

Amenorrhoea,  Menorrhagia,  and  Dysmenorrhoea 160 

Vicarious  Menstruation v 164 

The  Sexual  Impulse 166 

Nymphomania,  Anaesthesia  and  Psychopathia  Sexualis 184 

II.  THE  SEXUAL  EPOCH  OF  THE  MENA.CME 200 

Anatomical  Changes  in  the  Female  Genital  Organs  in  the  Period 
of  the  Menacme 209 

Pathology  of  the  Menacme 218 

Dyspepsia  Uterina 227 

Cardiopathia  Uterina 235 

Nervous    Diseases   Secondary   to   Diseases    of   the  Genital 
Organs ' 243 

Competence  for  Marriage  of  Women  suffering  from  Disease 250 

Hygiene  during  the  Menacme 261 

Copulation  and  Conception 284 

Copulation 284 

Conception 304 

Pathology  of  Copulation 323 

Vaginismus 337 

Cardiac  Troubles  Due  to  Sexual  Intercourse, 344 

Dyspareunia 347 

Fertility  in  Women 363 

The  Restriction  of  Fertility  and  the  Use  of  Means  for  the 
Prevention  of  Pregnancy 388 

The  Determination  ot  Sex 420 

I.   Statistical  Investigations 422 

II.  Anatomical  Investigations 446 

III.  Experimental   Investigations 452 

Sterility  in  Women 462 

Incapacity  for  Ovulation 470 

Interference  with  Conjugation,  Conditions  Preventing  Access 

of  the  Spermatozoa  to  the  Ovum 487 

Diseases  of  the  Ovaries  and  the  Fallopian  Tubes 489 

Diseases  of  the  Uterus 494 

Pathological  Changes  in  the  Cervix  Uteri 501 

[vii] 


viii  TABLE  OF  CONTENTS. 

II.  THE  SEXUAL  EPOCH  OF  THE  MENACME  —  Continued. 

Sterility  in  Women  —  Continued.  PAGE 

Displacements  of  the  Uterus 515 

Myoma  of  the  Uterus 523 

Diseases  of  the  Vagina  and  the  Vulva 526 

Secretions  of  the  Genital  Organs 528 

A.  Absolute  Sterility 540 

B.  Relative  Sterility 540 

-Sexual  Sensibility  in  Women 542 

Incapacity  for  Incubation  ot  the  Ovum 549 

-Only-Child-Sterility 561 

Operative  Sterility 563 

Table  Showing  the  Causes  of  Sterility  in  Women 569 

III.  THE  SEXUAL  EPOCH  OF  THE  MENOPAUSE 571 

The  Menopause 571 

Changes  in  the  Female  Reproductive  Organs  at  the  Menopause .  5.83 

The  Time  of  the  Menopause 593 

The  Age  at  which  the  Menopause  occurs 593 

1.  Race 594 

2.  The  Age  at  which  the  Menarche  Occurred 595 

3.  The  Woman's  Sexual  Activity 597 

4.  The  Social  Circumstances  of  the  Woman's  Life 599 

5.  General  Constitutional  and  Pathological  Conditions 599 

6.  Premature,  Delayed,    and    Sudden    Onset   of   the  Meno- 
pause    600 

Pathology  of  the  Menopause 608 

Diseases  of  the  Genital  Organs 608 

Diseases  of  the  Organs  of  Circulation 620 

Diseases  of  the  Digestive  Organs 630 

Diseases  of  the  Skin 632 

Disorders  of  Metabolism 635 

Diseases  of  the  Nervous  System 637 

Climacteric  Psychoses / 643 

Hygiene  during  the  Menopause 653 


LIST  OF  ILLUSTRATIONS  (Kisch). 


FIG.  -  PAGE 

1.  Curve  of  the  sexual  life  of  woman  from  the  tenth  to  the  sixtieth 

year  of  life 4 

2.  Portion  of  the  pelvic  viscera  in  the  female,  etc 9 

3.  The   distribution   of  the  pudic  nerve  in  the  female  perineal  and 

pubic  regions   n 

4.  The  distribution  of  the  lateral  sacral  arteries,  etc 14 

5.  Curve  of  menstrual  cycle 19 

6.  Curve  of  rhythmical  variations 20 

7.  Curve  of  beauty  of  woman 24 

8.  Internal  genital  organs  of  newborn  female  infant 51 

9.  Reproductive  organs  of  a  newborn  female  infant S2 

10.  Internal  genital  organs  of  a  girl  aged  eight  years 52 

11.  Reproductive  organs  of  a  girl  aged  ten  years S3 

12.  Female  external  genital  organs  of  a  virgin 54 

13.  The  external  genital  organs  of  a  virgin 55 

14.  Sagittal  section  of  the  female  pelvis 56 

15.  Primitive   follicles    58 

16.  Ripening  fcl  icles .' 61 

17.  Graafian  follicles   62 

18.  Annular  Hymen 64 

19.  Annular  Hymen  64 

20.  Semilunar  Hymen  65 

21.  Annular  Hymen  with  Congenital  Symmetrical  Indentations 65 

22.  Fimbriate  Hymen   65 

23.  Deflorated  Fimbriate  Hymen 65 

24.  Septate  Annular  Hymen 67 

25.  Septate  Semilunar  Hymen 67 

26.  Extremely    tough    Annular    Hymen    with    an    obliquely    disposed 

Septum    67 

27.  Septate  Hymen  with  Apertures  of  unequal  Size 67 

28.  Septate  Hymen  with  Apertures  of  unequal  Size 68 

29.  Hymen  with  rudimentary  Septum 68 

30.  Hymen  with  posterior  rudimentary  Septum 68 

31.  Labiate  Hymen  with  posterior  rudimentary  Septum 68 

32.  Hymen  with  anterior  rudimentary  Septum 69 

33.  Hymen  with  anterior  rudimentary  Septum  projecting  in  a  opini- 

form  Manner 69 

34.  Hymen  with  anterior  and  posterior  rudimentary  Septa 69 

35-  Hymen    with    filiform     Process    projecting    from    the     anterior 

Margin 69 

36.  Hymen  in  which  there  are  two  symmetrically  disposed  thinned 

Areas.  The  left  of  these  is  perforated 69 

37-  Very  unusual  form  of  Hymen .' 70 

38.  Semilunar  Hymen  with  cicatrized  Lacerations  in  its  Border 70 

39.  Deflorated  Semilunar  Hymen  with  laterally  disposed  symmetrical 

Lacerations   70 

40.  Deflorated  Annular  Hymen  with  several  cicatrized  Lacerations..  70 

41.  A.  Septate  Hymen  in  which  defloration  has  been  effected  through 

one  of  the   Apertures.     U.  Urethra.     Cl.   Gitoris.     H.   Cicatrized 

Margin.     C.  Septum.     B.  Lateral  view  of  Septum 70 

42.  Deflorated   Septate   Hymen 71 

[ix] 


x  LIST  OF  ILLUSTRATIONS. 

FIG.  PAGE 

43.  Hymen  with  larger  anterior  and  smaller  posterior  Apertures....     71 

44.  Carunculae  Myrtiformes  in  a  Primipara 71 

45.  Vaginal    Inlet   of  a   Multipara,   without   Carunculae   Myrtiformes. 

Slight  Prolapse  of  Anterior  and  Posterior  Vaginal  Walls 71 

46.  The  breast  of  a  virgin  aged  eighteen  years 73 

47.  Horizontal  section  through  the  female  bre*ast. 75 

48.  The  female  pudendum,  or  vulva,  with  the  labia  majora 204 

49.  Vestibule  of  the  vagina,  with  the  labia  minora  or  nymphae,  etc. . .   205 

50.  The  uterus,  the  left  Fallopian  tube  and  the  left  ovary,  etc 207 

51.  Female  internal  genital  organs  in  the  fully  developed  state 208 

52.  Sagittal  Section  through  the  Cervix  Uteri  of  a  Woman  twenty-six 

years  of  age.     Dendriform  branched  glands 217 

53.  Cervix  of  a  Woman  seventy-two  years  of  age,  with  glands  that 

have  undergone  cystic  degeneration 217 

54.  Sagittal  Section  through  the  Cervix  Uteri  of  a  Woman  sixty-five 

years  of  age.     The  glands  have  undergone  cystic  degeneration.  217 

55.  First  Stage.     A.     Entrance  of  a  Spermatozoon  into  the  Ovum  of 

Ascaris  Megalocephala.  B.  After  preparations  by  M.  Nuss- 
baum.  (Half  of  the  ova  only  are  depicted) •  • 306 

56.  Ovum  of  Asterahanthion  ten  minutes  after  Fertilization 306 

57.  Fusion  of  Male  Pro-nucleus  and  Female  Pro-nucleus  to  form  the 

Segmentation  Nucleus  of  the  Fertilized  Ovum 306 

58.  Passage    of    Spermatozoon    through   the    Zona    Pellucida    of   the 

Ovum  of  Asterakanthion 307 

59.  Ovum  of  Scorpaena  Scrofa  Thirty-five  Minutes  after  Fertilization.  307 

60.  Male   Pro-nucleus   and   Female   Pro-nucleus   in   Fertilized   Ovum 

of  Frog,  prior  to  the  Formation  of  the  Segmentation  Nucleus.  307 

61.  a.  b.   c.   Prostatic  calculi   from  normal   semen,     d.   Spermatozoa. 

e.  Large  and  small  cells,  some  containing  granules,  as  morpho- 
logical elements  of  semen,  f.  Spermatozoon  distorted  by  im- 
bibition of  water,  g.  Crystals  (after  Bizzozero) 311 

62.  Normal  Semen 311 

63.  Semen  consisting    chiefly    of    spermcrystals,    cylindrical    epithelium, 

and  small  granules  exhibiting  molecular  movement  —  but  con- 
taining no  spermatozoa 315 

64.  Oligozoospermia.     a.  Living    Spermatozoa,    b.    Dead    Spermato- 

zoa, c.  Pus  Corpuscles,  d.  Erythrocyte,  e.  Seminal  granules..  317 

65.  Septate  Hymen,  the  septum  having  a  tendinous  consistency 324 

66. 

67.  Lipoma    of  the   Right   labium   majus,   including  the  Vaginal    Inlet.  328 

68.  "Hottentot  Apron"  in  an  adult  Woman,  hanging  down  between 

the  thighs  (after  Zweifel) 329 

69.  Elephantiasis  of  the  Labia  Majora 330 

71.  Congenital    Atrophy    of    the    Uteras    (after    Virchow),    oi,    Ostium 

internum ;  oe,  Ostium  externum 500 

71. 

72.  Normal  Shape  of  the  Portio  Vaginalis 503 

73.  Conoidal  Shape  of  the  Portio  Vaginalis 503 

74.  "Apron-Shaped   Vaginal   Portion,     a.    Greatly  elongated  anterior 

lip;  b.  Shorter  posterior  lip  of  the  cervix 504 

75.  "Beak-Shaped"  Vaginal  Portion.     Posterior  aspect 504 

76.  Simple    Hypertrophy   of  the    Portio   Vaginalis,    which   projected 

from  the  Vulva 506 

77.  Elongated  Cervix,  bent  upwards 506 

78.  Cervical  Polypus,  originating  from  an  Ovulum  Nabothi 510 

79.  Ectropium  in  a  Case  of  Bilateral  Laceration  of  the  Cervix  (after 

A.  Martin) 514 

80.  Anteflexio    Uteri    (after    A.    Martin) 518 

81.  Retroflexio  Uteri  (after  A.  Martin) 520 


LIST  OF  ILLUSTRATIONS.  xi 

FIG.  PAGE 

82.  Mucus  from  the  Cervical  Canal,  taken  one  hour  after  sexual  in- 

tercourse, from  a  woman  suffering  from  chronic  endometritis. 
Among  the  epithelial  cells,  pus  cells,  and  finely  granular 
masses,  we  see  a  few  motionless,  dead  spermatozoa 531 

83.  Uterine  Mucous  Membrane  in  Endometritis  (after  A.  Martin)..   554 

84.  Sagittal  section  through  the  ovary  of  a  girl  aged  sixteen 583 

85.  Sagittal  section  through  the  ovary  of  a  woman  aged  seventy-two 

years    584 

86.  Diagrammatic  Representation  of  the  Graafian  Follicle 585 

87.  Ovary  of  a  Girl  aged  nineteen  years  (Normal  Size) 585 

88.  Ovary  of  a  Woman  seventy-two  years  of  age  (Normal  Size)....  585 

89 , 586 

90 587 

91-  •  •  •  :  • 588 

92.  Sagittal    Section    through    the    Cervix    of    a    Woman    twenty-six 

years  of  age.     Dendriform  branched   glands 588 

93.  Sagittal  Section  through  the  Cervix  of  a  Woman  sixty-five  years 

of  age.     Glands   which   have  undergone    Cystic   Degeneration.  589 

94.  Cervix  of  a  Woman  seventy  years  of  age.     The  Cervical  Glands 

have  undergone   Cystic   Degeneration 589 

95.  Ovula  Nabothi  in  the  Portio  Vaginalis 590 

96.  Vesicle  (Ovula  Nabothi)  from  the  Uterine  Mucous  Membrane..  591 

97.  Mucous  Glands  undergoing  Cystic  Degeneration... ,....,.  592 


THE  SEXUAL  LIFE  OF  WOMAN. 


By  the  sexual  life  of  woman  we  understand  the  reciprocal  action 
between  the  physiological  functions  and  pathological  states  of  the 
female  genital  organs  on  the  one  hand  and  the  entire  female  organ- 
ism in  its  physical  and  mental  relations  on  the  other;  and  the  object 
of  this  book  is  to  give  a  complete  account  of  the  influence  exercised 
by  the  reproductive  organs,  during  the  time  of  their  development, 
their  maturity,  and  their  involution,  on  the  life  history  of  woman. 

From  the  earliest  days  of  the  medical  art  this  sexual  life  of 
woman  has  aroused  in  the  leaders  of  medical  thought  the  highest 
interest,  and  for  this  reason  great  attention  has  been  directed,  not 
only  to  the  anatomy  of  the  genital  organs  and  to  the  diseases  of 
the  reproductive  system,  but  also  to  the  individual  manifestations  of 
sexual  activity  and  to  the  influence  exercised  by  these  on  the  female 
organism  as  a  whole. 

Several  works  by  Hippocrates  are  extant  on  this  subject,  among 
which  may  be  mentioned :  Kept  Fuvatxstr^  ^txreo?,1  a  treatise  on  the 
physiology  and  pathology  of  woman;  xspt  A^opatv?  which  discusses 
sterility  in  women;  xspt  xapOevtcuv ,3  a  treatise  on  the  pathological 
states  of  virgins.  These  writings  of  Hippocrates  contain  some 
very  remarkable  observations  on  the  influence  exercised  by  disorders 
of  the  reproductive  organs  on  the  general  health  of  women. 

Aristotle  wrote  at  some  length  on  the  functions  of  the  female 
genital  organs.  In  the  writings  of  Aretccus  and  Galen  on  the  dis- 
eases of  women  we  find  striking  observations,  as  for  instance,  in 
Galen's  DC  Locis  Affectis*  which  contains  a  "  Statement  of  the 
Similarity  and  Dissimilarity  of  Man  and  Woman."  Another  notable 
work  is  that  of  Albcrtus  Magnus,  entitled  De  Secretis  Mulierum? 

The  numerous  works  on  the  diseases  of  women  published  in  the 
sixteenth  century  consisted  for  the  most  part  of  a  repetition  of  the 
observations  of  ancient  writers.  The  gynecological  treatises  of  the 

1  Concerning  the  Feminine  Constitution. 

2  Concerning  the  Barren. 
8  Concerning  Virgins. 

4  On  the  Diseases  of  Regions. 
8  On  the  Secret  Parts  of  Women. 


2  THE  SEXUAL  LIFE  OF  WOMAN. 

eighteenth  century,  however,  bore  witness  to  an  increased  knowl- 
edge of  the  anatomy  of  the  female  reproductive  organs,  and  were 
illumined  by  Holler's  researches  on  the  functions  of  these  organs. 

The  subject  with  which  we  are  especially  concerned  is  discussed 
in  a  work  by  Boireau-Laffecteur,  Essai  snr  les  Maladies  Physiques 
et  Morales  des  fcmtnes*  Paris,  1793 ;  and  also  in  Marie-Clement's 
Considerations  Physiologiques  sur  les  Diverses  Epoques  de  la  Vie 
des  Fannies'1  Paris  1803.  ^n  me  same  connection  we  must  men- 
tion von  Humboldt's  treatise,  Ueber  den  Gcschlcchtsnnterschicd  und 
dessen  Einfluss  auf  die  organische  Natur.8  The  first  comprehensive 
work  in  which  an  exhaustive  inquiry  was  made  into  the  functional 
disorders  of  the  female  genital  organs  and  the  relation  of  these 
disorders  to  the  female  organism  as  a  whole  and  to  the  physical 
and  mental  peculiarities  of  woman  was  Bnsch's:  Das  Gcschlechts- 
leben  des  IVeibes,9  Leipzig,  1839. 

In  the  second  half  of  the  nineteenth  century  a  very  large  number 
of  monographs  were  published,  investigating  and  describing  the 
reflex  disturbances  produced  alike  in  the  individual  organs  and  in 
the  nervous  system  as  a  whole  by  changes  in  the  uterus  and  its 
annexa.  Many  of  these  works  will  be  mentioned  more  particularly 
in  the  course  of  this  treatise. 

The  sexual  life,  based  upon  the  purpose,  so  important  to  every 
creature,  of  the  propagation  of  the  species,  possesses  in  the  female 
sex  a  vital  significance  enormously  greater  than  sexual  activity 
possesses  in  the  male.  From  the  very  beginning  of  sexuality,  when 
the  idea  of  a  bisexual  differentiation  dawns  for  the  first  time  in  the 
brain  of  the  little  girl,  down  to  the  sexual  death  of  the  withered 
matron,  who  laments  the  loss  of  her  sexual  potency,  physical  and 
mental  activity,  work  and  thought,  function  and  sensation,  arise  for 
the  most  part,  wittingly  or  unwittingly,  from  that  germinal  energy 
which  is  the  manifestation  of  the  unalterable  law  that  the  existing 
organism  endeavors  to  reproduce  its  kind. 

Every  phase  of  the  sexual  life  of  woman,  from  the  threshold  of 
puberty  to  the  extinction  of  sexual  activity,  the  first  appearance  of 
menstruation,  the  complete  development  of  the  sexual  organs,  the 
act  of  copulation,  conception,  pregnancy,  parturition,  and  the  puer- 
perium,  finally  the  involutionary  process  which  accompanies  the 
cessation  of  menstruation  at  the  climateric  period — every  one  of 

6  Essay  on  the  Physical  and  Mental  Diseases  of  Women. 

7  Physiological  Considerations  on  the  Diverse  Epochs  of  the  Life  of  Woman. 

8  Concerning  Sexual  Differentiation,  and  Its  Influence  on  Organic  Nature. 
"The  Sexual  Life  of  Woman. 


INTRODUCTION.  3 

these  sexual  phases  entails  consecutive  physiological  processes  and 
pathological  changes  alike  in  the  individual  organs  and  in  the  nu- 
tritive condition  of  the  entire  organism,  in  the  functions  of  the 
cardio-vascular  apparatus,  of  the  brain  and  the  nerves,  of  the  skin 
and  the  sense-organs,  in  the  processes  of -digestion  and  general  meta- 
bolism. Herein  we  see  a  striking  illustration  of  the  old  saying  of 
von  Helmont,  propter  solum  uterum  mulicr  est  quod  est;w  also 
of  the  similar  aphorism  of  Hippocrates,  uterus  omnium  causa  mor- 
bornin  qui  mulicrcs  infest  ant;11  a  conception  summed  up  by  Goethe 
in  the  words  of  Mephistopheles : 

"  Es  ist  ihr  ewig  Weh  und  Ach 
So  tausendfach 
Aus  einem  Punkte  zu  kurieren." 

Just  as  in  a  tree  the  process  of  growth  is  made  manifest  to  the 
superficial  observer  by  the  pleasure  he  feels  at  the  sight  of  the  buds 
and  blossoms,  by  the  refreshment  he  obtains  from  the  fruit,  and  by 
the  sadness  which  the  withering  of  the  leaves  causes  him,  so  in  the 
sexual  life  of  woman  there  are  landmarks  which  no  one  can  pos- 
sibly overlook,  by  means  of  which  three  great  epochs  are  distin- 
guished. These  are:  puberty  (the  menarche),  recognized  by  the 
first  appearance  of  menstruation  and  the  awakening  of  the  sexual 
impulse;  sexual  maturity  (the  menacme),  in  the  fully  developed 
woman,  characterized  by  the  functions  of  copulation  and  reproduc- 
tion;  and  sexual  involution  (the  menopause),  in  which  we  see  the 
gradual  decline  and  ultimate  extinction  of  sexual  power  and  all  its 
manifestations.  In  all  these  three  epochs  the  sexual  life  of  woman 
not  only  affects  the  hidden  domain  of  the  genital  organs,  but  con- 
trols also  all  the  vegetative,  physical,  and  mental  processes  of  the 
body,  and  is  clearly  and  incontestably  apparent  in  all  vital  manifes- 
tations. What  Madame  de  Stael  said  of  love  is  indeed  true  of  the 
entire  sexual  life  of  woman:  I 'amour  n'est  qu'une  episode  de  la  vie 
de  I'honunc;  c'est  I'histoire  tout  entiere  de  la  fernme^2- 

The  sexual  life  of  woman  is  coextensive  with  the  peculiar  vital 
activity  of  the  female  sex,  for  it  endures  from  the  moment  when 

10  On  account  of  the  womb  alone  is  woman  what  she  is. 

11  The  womb  is  the  cause  of  all  the  diseases  from  which  women  suffer. 
12 "  Love  is  an  episode  merely  in  the  life  of  man ;   of    woman,  it  is  the 

entire  history."  But  this  epigram  of  Madame  de  StaeTs  will,  to  English 
readers,  be  more  familiar  in  the  form  in  which  it  was  cast  by  Byron  {Don 
Juan,  canto  i,  stanza  194)  : 

"  Man's  love  is  of  man's  life  a  thing  apart; 
Tis  woman's  whole  existence." 


4  THE  SEXUAL  LIFE  OF  WOMAN. 

individuality  first  begins  to  develop  out  of  the  indifferent  stage  of 
childhood  until  the  decline  into  the  dead-level  of  senility. 

To  illustrate  this  fact,  I  have  drawn  up  a  curve  of  the  sexual  life 
of  woman,  making  use  of  the  statistical  data  available  in  central 
Europe  regarding  the  age  'at  which  menstruation  first  appears,  the 
age  at  which  maidens  marry,  the  age  at  which  the  largest  number 
of  women  give  birth  to  a  child,  and  the  age  at  which  menstruation 
ceases;  and  reducing  the  figures  to  averages.  *  denotes  the  fif- 
teenth year  of  life,  as  the  average  age  at  the  menarche;  **  denotes 
the  twenty-second  year  of  life  as  the  average  age  at  marriage; 
***  denotes  the  thirty-second  year  of  life,  in  which  woman  exhibits 
her  maximum  fecundity ;  ****  denotes  the  forty-sixth  year  of  life 
as  the  average  age  at  the  menopause.  (Fie.  I.) 


FIG.  i. —  Curve    of    the  sexual  life   of  "woman   from   the  tenth  to  the 
sixtieth    year  of  life. 

Not  in  this  respect  alone,  however,  is  the  sexual  life  of  woman 
of  paramount  importance ;  it  is,  in  addition,  the  mainspring  of 
the  well-being  and  progress  of  the  family,  of  the  nation,  of  the 
entire  human  race.  In  the  evolution  of  man  from  the  primitive 
state  in  which  he  existed  merely  for  the  performance  of  vegetative 
functions  up  to  the  highest  stage  of  contemporary  culture,  in  the 
history  of  all  races  and  of  all  times,  the  sexual  life  has  been  a  most 


INTRODUCTION.  5 

potent  determining  factor.  With  that  life,  religion,  philosophy, 
ethics,  natural  science,  and  hygiene,  have  been  most  intimately  re- 
lated ;  for  that  life,  they  have  furnished  precepts  and  laws.  The 
history  of  the  sexual  life  is  identical  with  the  history  of  human 
culture. 

In  a  primitive  condition  of  society,  among  people  living  in  a  state 
of  nature  and  among  the  lower  races  of  mankind,  the  sexual  life  of 
woman  possesses  no  great  general  interest,  the  female  being  merely 
a  chattel ;  the  ownership  of  this  chattel,  moreover,  being  often 
temporary  and  transient.  The  investigations  of  anthropologists 
have  shown  that  among  primitive  people  this  form  of  property  is 
neither  highly  esteemed  nor  carefully  safeguarded.  In  such  so- 
cieties no  restraint  is  imposed  on  the  sexual  impulse,  which  is  grati- 
fied without  shame  and  without  formality.  No  hindrance  is  offered 
to  the  mutual  intercourse  of  the  two  sexes.  Chastity  in  the  females 
is  not  prized  by  the  males,  nor  do  the  latter  compete  for  the  favors 
of  the  former.  Procreation  is  no  more  than  a  gregarious  impulse 
of  the  masses  among  whom  the  common  ownership  of  all  booty  is 
a  matter  of  tribal  custom.  The  woman  has  no  disposing  power 
over  that  which  every  one  desires  and  which  every  one  has  the  right 
to  demand.  Very  gradually,  however,  a  change  takes  place  in 
this  respect,  so  that  in  every  period  of  social  life  since  the  very 
earliest,  the  modesty  of  young  girls,  the  high  valuation  put  upon 
the  preservation  of  virginity,  the  ethical  approbation  of  chastity  in 
the  wife,  respect  for  the  duties  and  rights  of  the  mother,  the  rever- 
ence felt  for  the  matron  —  all  these,  throughout  the  sexual  life  of 
woman,  have  had  a  civilizing,  ennobling,  and  elevating  effect. 
Thus,  as  .family  life  has  become  developed,  and  as  love  and 
marriage  have  been  more  highly  esteemed,  woman  has  become 
the  much-prized  embodiment  of  all  that  is  beautiful  and  good, 
of  all  that  is  summed  up  in  the  idea  of  the  "  housewife,"  and 
her  sexual  life  has  been  more  completely,  more  ideally  admired. 
The  danger  is  not  remote,  however,  that  the  leveling  tendencies  of 
the  present  day,  and  an  inclination  to  despise  the  sexual  life  of 
woman,  far  from  resulting  in  a  further  elevation  of. the  social 
status  of  womanhood,  will  result  rather  in  its  abasement. 

The  Bible,  as  we  may  expect  from  the  patriarchal  relationships  of 
the  women  of  that  time,  bears  witness  to  the  worth  of  woman,  and, 
whilst  esteeming  childbearing,  refers  to  yet  higher  duties.  Precise 
religious  and  social  precepts  are  furnished  for  all  the  phases  of 
sexual  life. 


6  THE  SEXUAL  LIFE  OF  WOMAN. 

In  classical  antiquity,  also,  we  see  that  woman  rose  to  some  extent 
above  the  low  position  she  had  previously  occupied  in  the  family 
circle  and  in  society  at  large.  Both  among  the  Greeks  and  among  the 
Romans,  there  was  open  to  women  a  more  intimate  place  in  social  life 
and  a  more  influential  role  in  the  life  of  the  family,  than  would  have 
been  their  portion  regarded  merely  in  relation  to  their  childbearing 
activity.  Amongst  the  Germans  in  the  very  earliest  times,  chastity 
gave  rise  to  purer  and  more  moral  sexual  relations ;  whereas  among 
the  Slavonic  peoples  the  conception  of  woman  as  the  childbearer 
continued  to  dominate  these  relations. 

In  consequence  of  the  diffusion  of  Christianity,  woman  became 
man's  companion  and  equal,  and  her  life,  the  sexual  life  included, 
acquired  a  deeper  significance,  owing  to  the  stress  which  that  re- 
ligion laid  on  chastity  as  a  virtue,  and  as  a  result  of  the  educational 
influence  of  woman  in  the  family  circle. 

With  the  progress  of  civilization  the  sexual  life  of  woman  comes 
to  exhibit  its  activities  only  within  the  bounds  of  morality  and  law, 
which  in  human  society  have  replaced  the  crude  rule  of  nature,  and 
have  supplied  regulations  adapted  to  the  changing  phases  of  sexual 
vital  manifestations.  The  wise  adaptation  of  these  regulations  re- 
quires, however,  a  full  understanding  of  the  mental  and  physical 
processes,  an  exact  recognition  of  the  bodily  states  and  intellectual 
sensibilities,  of  woman  regarded  as  a  sexual  being. 

Modern  culture  and  the  social  organization  of  the  present  day, 
in  association  with  the  resulting  sexual  neuropathy  of  women,  have 
exercised  on  their  sexual  life  an  influence  as  powerful  as  it  is  un- 
favorable, manifesting  itself  in  the  overpowering  frequency  of  the 
diseases  of  women.  In  one  of  the  most  thoughtful  books  ever  writ- 
ten on  the  subject  of  woman,  Michclct's  L'Amour,n  the  author  re- 
marks that  every  century  is  characterized  by  the  prevalence  of  cer- 
tain diseases :  thus,  in  the  thirteenth  century,  leprosy  was  the  domi- 
nant disease ;  the  fourteenth  century  was  devastated  by  bubonic 
plague,  then  known  as  the  black  death ;  the  sixteenth  century  wit- 
nessed the  appearance  of  syphilis ;  finally,  as  regards  the  nineteenth 
century,  "  se  sicde  sera  nommc  cclui  des  maladies  dc  la  niatrice.1* 
It  is  certain  that  the  education  and  mode  of  life  of  the  modern 
woman  belonging  to  the  so-called  upper  classes  are,  as  far  as  sexual 
matters  are  concerned,  in  direct  opposition  to  those  that  are  agree- 
able to  nature  and  those  that  the  laws  of  health  demand. 

13  On  Love. 

14  "  This  century  will  be  known  as  the  century  of  the  diseases  of  the  uterus." 


INTRODUCTION.  7 

Even  before  sexual  development  begins,  before  the  physical  ripen- 
ing of  the  reproductive  organs  to  functional  activity,  the  imagination 
of  young  girls  is  often  prematurely  occupied  with  sexual  ideas  in 
consequence  of  unsuitable  literature,  owing  to  visits  to  theatres  and 
exhibitions,  or  on  account  of  social  intercourse  with  young  men 
who  are  not  overscrupulous  in  the  selection  of  topics  for  conversa- 
tion. From  the  time  of  puberty  up  to  the  time  of  marriage  the 
growing  woman  is  under  the  influence  of  the  now  awakened  sexual 
impulse,  which  experiences  ever-renewed  stimulation.  A  sedentary 
mode  of  life,  unsuitable  nutriment,  and  the  early  enjoyment  of  alco- 
holic beverages,  exhibit  their  inevitable  result  in  the  frequency  with 
which,  in  this  epoch  of  the  sexual  life,  chlorotic  blood-changes,  neu- 
rasthenic conditions,  and  diverse  symptoms  of  irritation  of  the  genital 
organs,  make  their  appearance.  Thus,  when  marriage,  so  often  un- 
duly postponed  in  consequence  of  the  condition  of  modern  society, 
does  at  length  take  place,  it  is  apt  to  find  the  woman  not  only  fully 
enlightened  as  regards  sexual  matters,  but  often  in  a  state  of 
nervous  weakness  from  sexual  stimulation,  one  of  the  type  whose 
characteristics  have  been  happily  summed  up  by  the  French  writer 
Prrrost  in  the  expression  doni-vierge.15  The  conjunction  of  this 
state  of  affairs  in  the  bride  with  the  frequent  partial  impotence  of 
the  bridegroom,  who  has  already  dissipated  the  greater  part  of  his 
virile  power  before  entering  upon  marriage,  leads  often  to  the 
appearance  of  vaginismus  and  other  sexual  neuroses  in  young  mar- 
ried women.  Even  more  disastrous  in  its  consequences  as  regards 
the  future  sexual  .life  of  the  wife  is  the  ever-increasing  frequency 
of  gonorrhceal  infection  in  the  first  days  of  marital  intercourse,  with 
all  the  evil  results  of  that  infection.  On  the  other  hand,  an  ever- 
larger  proportion  of  girls  belonging  to  the  "  middle  and  upper 
classes,"  abstaining  alike  from  the  good  and  the  evil  results  of  mar- 
riage, falls  under  the  yoke  of  sexual  impulses  denied  satisfaction  or 
gratified  by  abnormal  means,  and  suffers  in  consequence  both  phy- 
sically and  mentally.  Further  sources  of  injury  arising  from  the 
conditions  of  modern  social  life  are  to  be  found  in  the  neglect  by 
women  of  the  well-to-do  classes  of  the  duty  of  suckling  their  chil- 
dren, and  in  the  ever-increasing  frequency  with  which  the  women 
of  these  classes,  after  giving  birth  to  one  or  two  children,  resort  to 
the  use  of  measures  for  the  prevention  of  pregnancy,  which  result  in 
serious  consequences  as  regards  both  the  nervous  system  and  the 
genital  organs  of  the  women  concerned.  Thus  there  comes  an 
accelerated  ebb  in  the  sexual  life,  leading  to  a  premature  appearance 

15  Half-virgin. 


8  THE  SEXUAL  LIFE  OF  WOMAN. 

of  the  general  phenomena  of  senility,  with  a  cessation  of  the  men- 
strual flow.  The  modern  wife,  who  claims  the  right  to  lead  the  life 
that  best  pleases  her,  will  be  more  rapidly  overtaken  by  sexual  death. 

For  the  elucidation  of  the  manifold  reflex  and  other  processes 
which  are  dependent  upon  or  accompany  the  sexual  phases  of 
woman,  we  must  in  the  first  place  consider  the  anatomical  changes 
and  physiological  functions  of  the  female  reproductive  organs  char- 
acteristic of  the  several  periods  of  sexual  life  which  have  already 
been  distinguished.  We  must  not  fail  also  to  take  into  consideration 
the  mental  states  which  accompany  and  characterize  these  respective 
phases. 

The  anatomical  changes  which  occur  in  the  female  genital  organs 
•during  these  different  phases  of  sexual  life  give  rise  to  a  number  of 
manifold  local  stimuli,  increasing  and  decreasing,  varying  greatly 
in  intensity  and  area  of  distribution,  upon  which  depend  the  reflex 
effects  and  remote  manfestations  in  the  sphere  of  the  nervous  and 
circulatory  systems. 

We  must  first  consider  the  changes  in  the  ovaries,  which  play  an 
etiologically  important  part.  At  the  onset  of  puberty,  the  follicular 
masses  of  the  ovary  exhibit  a  more  active  growth,  the  follicles  in- 
crease in  size,  with  their  contained  ova  they  approach  the  surface, 
and  finally,  by  the  bursting  of  the  follicles,  the  ova  are  extruded. 
Then,  in  the  life-phase  in  which  conception  occurs,  and  under  the 
influence  of  the  hyperaemia  of  all  the  pelvic  viscera  that  accompanies 
this  process,  a  notable  development  of  the  corpus  luteum  takes 
place,  this  latter  body  reaching  its  maximum  size  in  the  eleventh 
week  of  pregnancy,  subsequently  undergoing  involution  and  lead- 
ing to  the  formation  of  a  considerable  scar.  Finally,  in  the  critical 
period  of  life  in  which  the  menstrual  flow  ceases,  a  continually  in- 
creasing growth  and  new  formation  of  connective  tissue-stroma 
takes  place  in  the  ovaries  at  the  expense  of  their  cellular  constituents, 
and  a  regressive  metamorphosis  of  the  graafian  follicles  occurs. 

In  association  with  these  sexual  processes  there  ensues  a  series 
of  striking  changes  in  the  shape  and  consistency  of  the  ovaries,  af- 
fecting both  the  surface  and  the  parenchyma  of  these  organs,  and 
capable  of  stimulating  the  nervous  ramifications  in  their  tissue. 
In  this  connection  it  is  worthy  of  note  that  the  branches  supplying 
the  ovaries  from  the  spermatic  plexuses  of  the  sympathetic  contain 
a  considerable  proportion  of  sensory  fibres. 

Quite  as  significant,  moreover,  as  the  changes  in  the  ovaries,  are 
those  which,  in  the  course  of  the  sexual  life,  the  uterus  undergoes, 


INTRODUCTION. 


Visceral  peritoneum  covering  \  I  A 
the  posterior  or  intestinal  Nl  // 
surface  of  the  uterus  /\  M, 


Paiietal   peritoneum  of  the  \ 
lateral  wall  of  the  pelvis 


/  Sacral  promontory 


Utero  sacral  liga- 
ment or  fold  of 
Douglas 


Extractor  uteri 
muscle  in  trans- 
verse section 


Visceral  peritoneum^  /  /   Mm 


Pouch  of  Dougla3 
or  rectovaginal 
pouch 


Sigmoid    flexure  of    the 
colon 


Sigmoid      meso- 
colon 


Suspensory 
ligament    of 
the  ovary 
Fallopian 
tube 


Mcsome- 
trium 


arametrium 

Round  liga- 
ment of  the 
uterus 
Uterovesi- 
cal  pouch 
Lateral 
false  liga- 
ment    of 
~~  the 
'  .  bladder 


Tip  of  coccyx 

Vagina' 

Levator  ani  muscle  * 

Anus  • 
External  or  superficial  sphincter  of  the  anus 

Perineal  c\irve  of  the  rectum 


Pubis 
Visceral  peritoneum 

\      \       \Body  of  the  bladder 
\      \Urethra 

Erectile  tissue  of  the  urethra 
Urogenital  diaphragm 
Vaginal  bulb,  or  bulb  of  the  vestibule 
Bartholin's  gland 


FIG.  2. —  Portion  of  the  pelvic  viscera  in  the  female,  and  their  relation  to  the  muscles  of  the 
pelvic  outlet  (or  perineal  muscles),  shown  in  the  left  half  of  the  pelvis,  seen  from  the  right 
side. — The  parametrium.  (From  Toldt:  Atlas  of  Human  Anatomy. — Rebman  Company, 
New  .York.) 


io  THE  SEXUAL  LIFE  OF  WOMAN. 

in  shape  and  size,  in  its  muscular  substance  and  mucous  lining,  and 
in  its  vascular  and  nervous  supply. 

At  the  time  of  puberty  the  infantile  uterus  undergoes  changes 
affecting  both  its  external  form  and  the  shape  of  its  interior  cavity. 
The  body  of  the  uterus  enlarges  to  the  size  characteristic  of  sexual 
maturity,  and  its  mucous  membrane  becomes  the  seat  of  periodic 
changes.  This  waxing  and  waning  growth  and  transformation  of 
the  uterine  mucous  membrane  continues  throughout  the  period  of 
menstrual  activity,  the  most  superficial  layers  6f  the  membrane 
being  shed  during  menstruation,  a  process  followed  by  regeneration, 
which  is  itself  succeeded  by  the  premenstrual  thickening.  When 
conception  occurs,  still  more  extensive  changes  ensue,  the  fertilized 
ovum  becoming  imbedded  in  the  uterine  mucous  membrane,  and  the 
pregnant  uterus,  in  shape  and  structure  and  in  the  respective  re- 
lations of  the  body  and  neck  of  the  organ,  in  the  increasing  dis- 
tension of  its  veins  and  the  increasing  size  of  its  nerves,  becoming 
adapted  to  the  important  functions  it  has  now  to  fulfil.  When  these 
have  been  fulfilled,  and,  parturition  having  taken  place,  the  uterus 
is  empty  once  more,  the  organ  again  adapts  itself  to  altered  cir- 
cumstances by  the  process  of  involution.  Later,  in  the  climacteric 
period,  a  slow  regressive  process  occurs,  the  outward  manifestation 
of  which  is  the  cessation  of  the  menstrual  flow,  characterized  ana- 
tomically by  atrophy  of  the  muscular  tissue  of  the  uterus  and  of 
its  vascular  apparatus,  by  the  dessication  of  its  mucous  membrane; 
by  obliteration  of  the  lumen  of  the  uterine  cavity,  and  ultimately  by 
senile  degeneration  and  atrophy  of  the  now  entirely  functionless 
organ,  so  that  it  becomes  an  insignificant,  cicatrized,  solid  body. 

Next  to  the  ovaries  and  the  uterus,  it  is  the  pelvic  fascia  which 
in  its  entire  architectonic  structure  as  well  as  in  its  individual  parts 
undergoes  the  most  notable  changes  in  consequence  of  the  proc- 
esses of  generation. 

A  short  account  of  the  nerves  and  blood  vessels  of  the  female 
genital  organs  appears  indispensable,  to  facilitate  the  comprehen- 
sion of  the  manner  in  which  sexual  processes  are  influenced  by  the 
nervous  system,  and  to  demonstrate  the  intimate  connection  be- 
tween the  blood-supply  of  the  genital  apparatus  and  the  general 
circulation. 

The  complex  nervous  network  of  the  female  sexual  organs  is 
supplied  by  spinal  as  well  as  by  sympathetic  fibres,  the  fibres  from 
the  two  systems  anastomosing  in  a  very  intimate  manner. 

The   greater  number   of  the   spinal   nerves   distributed   to  the 


INTRODUCTION. 


ii 


Gluteus  maximus  muscle 


Coccygeus   mus<  let 


External   or    superficial  \ 
sphincter  of  the  anus  \ 


Anococcygeal  or  subcaudal  nerves 

Inferior  haemorrhoidal  nerve 
Perineal  nerve 


Levator  ani  muscle 
Ischiorectal  fossa 


Constrictor  or  com-  / 
pressor    urethrae     or/ 
transversus       perinei 
profundus  muscle 

Ischiocavernosus    or 
erector  penis  muscle 


Bulbocavernosus  or  ejac- 
ulator  penis   muscle 


Labium  majus( 

Glans  clitoridis 


Branches  of  the 
inferior  puden- 
dal  nerve 


Long  labial  nerves 


Dorsal  nerve  cf  the  clitoris 


Mons  Veneris 


FIG.  3. — The  distribution  of  the  pudic  nerve,  n.  pudendus,  in  the  female  perineal  and  pubic 
regions.  The  trunk  of  the  pubic  nerve,  11.  pudendus,  is  covered  by  the  gluteus  maximus  muscle. 
On  the  right  side  of  the  body  the  branches  of  the  inferior  pudendal  nerve,  rami  perineales,  nervi 
cutanei  fermoris  posterioris  have  been  dissected  out ;  but  the  branches  of  this  nerve  to  the  labium 
majus  have  been  cut  short.  The  formation  of  the  anococcygeal  or  subcaudal  nerves,  nn.  anococcy- 
gei,  out  of  the  posterior  primary  division  of  the  coccygeal  nerve  and  out  of  the  perforating 
branches  which  arise  from  the  anterior  primary  divisions  of  the  fourth  and  fifth  sacral  nerves  and 
the  coccygeal  nerve.  (From  Toldt :  Atlas  of  Human  Anatomy. — Rebman  Company,  New  York.) 


12  THE  SEXUAL  LIFE  OF  WOMAN. 

genital  organs  arise  from  the  lumbar  portion  of  the  spinal  cord, 
pass  as  rami  communicantes  to  the  first  four  lumbar  ganglia  of  the 
great  sympathetic  cord,  whence  they  proceed  to  the  series  of 
symmetrical  (paired)  and  asymmetrical  (azygos)  sympathetic 
plexuses  in  front  of,  and  adjacent  to  the  abdominal  aorta,  which 
already  contain  afferent  and  efferent  spinal  fibres  derived  frorn  the 
pneumogastric,  phrenic,  and  splanchnic  nerves.  A  small  number 
only  of  coarse  nerve-filaments,  a  larger  number  of  fine  nerve- 
filaments,  derived  from  the  sacral  nerves,  proceed  direct  to  the 
internal  genital  organs;  many  of  these  fibres  enter  the  lower  ex- 
tremity of  the  pelvic  or  inferior  hypogastric  pleans,  some  pass  to 
the  cervical  ganglia  of  the  uterus.  Below  the  bifurcation  of  the 
aorta  and  in  front  of  the  sacral  promontory,  a  large  number  of  the 
uterine  nerves,  both  of  spinal  and  of  sympathetic  origin,  unite  to 
form  an  azygos  plexus  which  has  been  shown  by  experiment  to 
possess  great  functional  importance.  Anatomically  this  consti- 
tutes the  upper  undivided  portion  of  the  hypogastric  plexus,  which 
is  the  downward  continuation  of  the  abdominal  aortic  sympathetic 
plexus;  but  inasmuch  as  it  is  the  principal  channel  of  nervous  im- 
pulses to  the  uterus  it  is  often  known  at  the  present  day  as  the 
great  uterine  plexus  (plc.nts  utcriiius  magnus).  The  nerves  to 
the  ovary  and  Fallopian  tube  (ovarian  nerves)  are  derived  from 
the  spermatic  (ovarian)  plexus,  an  offshoot  of  the  renal  plexus; 
as  the  spermatic  plexus  descends,  it  is  reinforced  by  branches  frorn 
the  abdominal  aortic  plexus,  these  branches  often  arising  from 
a  small  ganglion  (spermatic  ganglion).  The  hypogastric  or  great 
uterine  plexus,  single  and  median  above,  divides  below  into  the 
paired  pelvic  or  inferior  hypogastric  plexuses,  which  pass  down- 
ward and  forward  on  either  side  of  the  rectum ;  these  plexuses  are- 
reinforced  by  spinal  elements  derived  from  the  sacral  nerves. 
Before  the  terminal  expansions  of  the  pelvic  or  inferior  hypogas- 
tric plexus  enter  the  tissues  of  the  internal  genital  organs,  the 
bladder,  and  the  rectum,  small  masses  of  ganglionic  matter  are  inter- 
spersed among  the  nerve  fibres. 

To  the  above  general  sketch,  which  has  been  based  on  the 
synoptical  description  of  Chrobak  von  Rosthorn,  must  be  added 
a  more  detailed  account  of  the  innervation  of  the  ovaries,  this 
branch  of  the  subject  being  of  especial  importance.  The  nerves  of 
the  ovary  are  derived  from  the  sympathetic  system,  in  part  from 
the  spermatic  ganglion,  in  part  from  the  second  renal  ganglion, 
and  in  part  from  the  superior  mesenteric  plexus.  The  nerves  of 


INTRODUCTION.  13 

the  ovary  are  for  the  most  part  vascular  nerves,  which  unite  before 
entering  the  ovary  to  form  the  ovarian  plexus,  and  then  pass  into 
the  hilum  with  the  vessels,  envelop  the  vessels  of  the  medullary 
layer,  and  thence  pass  to  the  follicuiar  region;  exceedingly 
numerous,  they  form  a  close-meshed  network,  surrounding  all  the 
vessels  up  to  the  finest  capillary  ramifications;  those  fibres  which 
terminate  in  the  capillary  walls  and  those  also  which  reach  the 
follicles  are  regarded  by  Riese  as  sensory.  The  great  trunks  of 
the  uterine  nerves  are  transversely  disposed  in  relation  to  the  great 
lateral  vessels  of  the  uterus,  and  passing  inward  toward  the  mucous 
membrane  they  break  up  into  pencils  of  filaments;  the  uterine 
nerves  proper  are  distributed  for  the  most  part  to  the  muscular 
substance.  In  the  Fallopian  tubes,  the  nerves  form  arches  around 
the  lumen  of  the  tube;  some  fibres  also  pass  to  the  longitudinal 
folds  of  the  mucous  membrane. 

This  expansion  of  the  nerves  of  the  cerebrospinal  and  sympa- 
thetic systems  in  the  female  reproductive  organs  manifests  the 
multiple  interconnection  of  the  two  systems  in  this  region,  and 
proves  beyond  doubt  that  the  sensory  nerves  of  the  genital  organs 
have  manifold  connections  with  the  motor  tracts  of  the  whole 
organism  on  the  one  hand  and  with  the  sensory  ganglia  of  the  central 
nervous  system  on  the  other,  and  in  addition  with  the  vasomotor 
centres  and  with  efferent  motor  and  secretory  fibres. 

As  regards  the  vascular  system  of  the  female  genital  organs,  the 
latter  are  supplied  by  the  internal  iliac  artery.  One  of  the  two 
terminal  branches  of  the  common  iliac,  the  internal  iliac  artery, 
descends  into  the  pelvis  over  the  sacro-iliac  synchondrosis.  Its 
branches  may  be  arranged  in  four  groups:  anterior  group,  the 
hypogastric,  iliolumbar,  and  obturator  arteries;  posterior  group, 
the  lateral  sacral,  gluteal,  and  sciatic  arteries;  internal  group,  the 
inferior  vesical,  uterine,  and  middle  hgemorrhoidal  arteries ;  in- 
ferior group,  comprising  a  single  artery  only,  the  internal  pudic; 
the  uterine  artery  supplies  the  uterus  and  the  vaginal  fornices;  the 
ovarian  artery  supplies  the  ovary,  the  Fallopian  tube,  and  the  broad 
ligament  of  the  uterus;  the  vaginal,  cervicovaginal,  or  vesicova- 
ginal  artery  supplies  the  vagina;  the  internal  pudic  artery  supplies 
the  vestibule  and  the  clitoris ;  the  superior  and  inferior  external 
pudic  arteries  (branches  of  the  femoral  artery)  supply  the  labia 
majora.  The  veins  of  the  female  genital  organs  correspond  in 
general  to  the  arteries  in  their  course  and  nomenclature,  and  empty 
their  blood  into  the  internal  iliac  vein. 


THE  SEXUAL  LIFE  OF  WOMAN. 


Left  common  iliac  artery 


Superior  haem- 
orrhoidal  ar- 
tery 


Left  external  iliac  artery 


Left  internal  iliac  artery 
Obliterated    hypogastric    artery 


Left  ovary  x 

Ovarian  artery  (in  the  suspen- 
sory ligament  of  the  ovary) 


Mesosalpynx^ 

Ovarian  branch  of    the 
uterine  artery  .„ 

Fallopian   tube 

Tubal    branch    of 
the  uterine  artery 


Round 
ment    of 
uterus 

Viscera]    peri- 
toneum of  the  ^ 
urinary  bladder 
Dorsal  artery  of 
the  clitoris 
Artery  of  the  cor- 
pus     cavernosum 
of  the  clitoris 
Divided      anasto- 
moses of  the  vagi- 
nal bulb,  or  bulb  of  the 
vestibule  with  the  cor- 
pora  cavernosa  of  the 
clitoris 

Urethra 

Deeplayer.of  the  trian- 
gular ligament  of 
the  urethra  ^ 

Artery  of  the  bulb 
Vaginal  bulb  or   bulb  of    the  . 

vestibule  S 

Offset    of   the  internal    pudic     ^ 
artery    to    the    urogenital    dia- 
phragm and  to  the  urethra 


Left  ureter 
Vagina 
Levator  ani  muscle 


Internal    pudic   artery  (artery 

of  the  clitoris) 


Bartholin's  gland 


FIG.  4.- —  The  distribution  of  the  lateral  sacral  arteries,  the  superior  haemorrhoidal 
or  superior  rectal  artery,  the  uterine  artery,  the  ovarian  artery  and  the  distal  portion 
of  the  internal  pudic  artery.  (FromToldt:  Atlas  of  Human  Anatomy. — Rebman  Com- 
pany, New  York.) 


INTRODUCTION.  15 

Attention  must  also  be  paid  to  the  extremely  rich  lymphatic 
vascular  system  of  the  female  genital  apparatus.  The  body  of  the 
uterus  and  the  annexa  of  that  organ,  the  neck  of  the  uterus  and 
the  vaginal  fornices,  the  middle  segment  of  the  vagina,  the  lower 
segment  of  the  vagina,  the  vestibule  and  the  external  genital 
organs  —  each  of  these  possesses  an  independent  set  of  lymphatic 
vessels,  leading  moreover  to  independent  groups  of  lymphatic 
glands.  It  may  be  said  that  the  lymph  from  the  vulva  passes  to 
the  inguinal  glands,  that  from  the  vagina  and  the  neck  of  the 
uterus  to  the  internal  and  the  external  iliac  lympathic  glands,  that 
from  the  upper  part  of  the  uterus  and  also  that  from  the  ovaries 
and  Fallopian  tubes  to  the  median  group  of  lumbar  lymphatic 
glands  (also  known,  from  their  position  in  front  of  the  aorta  and  the 
vena  cava,  as  the  aortic  lymphatic  glands)  (Chrobak  von  Rost- 
horn}. 

The  important  influence  which  the  genital  processes  exercise  on 
the  female  organism  as  a  whole  is  established  not  only  by  the 
anatomical  relations  just  described  but  also  by  a  number  of  physio- 
logical investigations  and  experiments  and  by  the  result  of  opera- 
tions on  the  female  genital  organs. 

Thermic  and  mechanical  stimulation  of  the  female  genitals  has, 
as  my  own  experiments  have  shown,  a  notable  influence  on  the 
heart  and  the  general  circulation.  In  these  experiments,  when 
uterine  douches  were  given  at  temperatures  of  4°  C.  (39°  F.)  and 
45°  C.  (113°  F.),  the  reflex  nervous  impulse  which  resulted  from 
these  manipulations  had  a  two-fold  influence  on  the  circulation, 
manifesting  itself  first  by  an  immediate  and  considerable  augmenta- 
tion in  the  functional  activity  of  the  heart,  the  frequency  of  which 
was  increased  in  a  degree  proportional  to  the  nervous  sensibility 
of  the  individual,  and  secondly  by  a  notable  rise  in  blood  pressure. 

With  a  view  to  determining  the  influence  of  stimulation  of  the 
ovary  on  blood-pressure,  Rohrig  carried  out  some  experiments  on 
bitches,  from  which  it  appeared  that  electrical  stimulation  of  the 
ovary  invariably  produced  a  remarkable  inc.  ease  in  the  general 
blood-pressure,  an  increase  ranging  from  twelve  to  twenty-four 
millimeters  of  mercury.  It  further  appeared  in  the  course  of  these 
experiments  that  toward  the  end  of  the  period  of  stimulation  the 
rise  in  blood-pressure  was  always  followed  by  a  decline;  to  which, 
however,  a  renewed  rise  of  blood-pressure  succeeded  after  the 
stimulation  was  discontinued,  provided  the  duration  of  this  had  not 
been  excessive.  Only  after  this  second  rise  was  the  normal  mean 
blood-pressure  regained.  Finally  it  was  established  that  the  pro- 


i6  THE  SEXUAL  LIFE  OF  WOMAN. 

nounced  phenomena  of  vagus-irritation  exhibited  by  the  curve 
during  and  immediately  after  the  stimulation  of  the  ovary  were 
invariable  concomitants  of  the  rise  of  blood-pressure  produced  by 
such  stimulation. 

According  to  the  observations  of  Federns,  the  blood-pressure 
undergoes  a  rhythmical  change  between  one  menstrual  period  and 
the  next,  the  pressure  curve  being  normally  at  its  lowest  at  the 
time  of  the  commencement  of  the  flow,  and  at  its  highest  at  some 
time  during  the  two  days  immediately  preceding  the  flow.  This 
rhythmical  change  of  blood-pressure  manifests  itself  also  some 
time  before  the  first  onset  of  menstruation,  when  the  approach  of 
puberty  is  indicated  only  by  the  menstrual  molimina. 

Observations  made  by  Kretschy  in  a  patient  with  a  gastric  fistula 
have  proved  the  influence  exercised  on  gastric  digestion  by  the 
physiological  processes  occurring  in  the  female  reproductive  organs. 
In  this  patient,  his  attention  was  especially  directed  to  determining 
at  what  period  of  digestion  the  secretion  of  acid  by  the  stomach 
attains  its  maximum,  and  how  that  secretion  increases  and 
diminishes.  He  observed  that  the  digestion  of  breakfast  was  com- 
pleted in  four  and  one-half  hours,  the  acid-maximum  occurring  in 
the  fourth  hour,  and  the  reaction  of  the  gastric  contents  becoming 
neutral  one  and  one-half  hours  later.  This  apparently  constant 
acid-curve  began,  however,  to  become  irregular  as  soon  as  the 
first  symptoms  of  the  approach  of  menstruation  became  apparent. 
When  the  flow  had  actually  begun,  he  found  that  the  reaction 
of  the  gastric  contents  remained  acid  throughout  the  entire  day. 
As  soon  as  the  flow  was  over,  the  normal  acid-curve  was  im- 
mediately reestablished. 

These  observations  have  been  confirmed  by  Fleischer.  This 
investigator  carried  out  his  researches  in  menstruating  women 
with  normal  stomachs,  and  found  that  with  the  appearance  of 
the  catamenia  the  process  of  digestion  was  almost  always  notably 
retarded,  but  that  with  the  diminution  and  cessation  of  the  flow 
digestion  returned  to  the  normal. 

By  stimulation  of  the  central  segment  of  the  divided  hypogastric 
or  great  uterine  plexus,  Cyon  was  able  to  provoke  vomiting,  a  con- 
firmation of  the  well-known  physiological  fact  that  irritative  disturb- 
ances of  the  female  reproductive  organs  have  a  reflex  influence  on 
the  vomiting  centre. 

It  is  also  clearly  established  that  diverse  stimulation  of  peri- 
pheral nerves,  those  for  instance  of  the  mammary  gland,  of  the 
internal  genitals,  or  of  the  epigastrium,  is  capable  of  affecting  the 
motor  centre  of  the  uterus. 

Worthy  of  note  also  are  Strassmanris  experiments,  showing  that 


INTRODUCTION.  17 

rise  of  pressure  in  the  ovary  causes  swelling  and  structural 
changes  in  the  uterine  mucous  membrane. 

Striking  also  are  Neusser's  discoveries  that  during  menstruation 
there  is  an  increase  in  the  eosinophil  cells  of  the  blood,  and  that 
by  the  intermediation  of  the  sympathetic  nervous  system  the 
ovaries  exercise  an  influence  on  the  haematopoietic  function  of 
the  red  marrow  of  the  bones.  Most  noteworthy  is  the  connection 
between  the  functional  activity  of  the  ovaries  and  osteomalacia. 
In  this  disease  of  metabolism  we  have  to  do,  according  to  Fehling's 
now  generally  accepted  assumption,  with  a  trophoneurosis  of  the 
bones,  a  stimulation  of  the  vasodilator  nerves  of  the  osteal  vessels, 
dependent  on  a  reflex  impulse  from  the  ovaries.  The  connecting 
path  between  the  ovaries  and  the  bones  Ncusscr  finds  in  this  case 
also  in  the  sympathetic  nervous  system. 

The  reflex  influence  exercised  on  the  heart  and  the  general  cir- 
culation has  been  shown  also  by  the  results  of  operations  on  the 
female  genital  organs.  In  cases  in  which  the  ovaries  have  been 
removed,  or  in  which  these  organs  have  been  roughly  handled, 
He  gar  has  noticed  a  great  diminution  in  the  frequency  of  the 
pulse,  sometimes  even  cessation  of  the  heart's  action.  In  similar 
circumstances  Champoniere  also  observed  as  a  rule  diminished 
frequency  of  the  pulse,  but  in  some  cases  increased  frequency. 
Mariagalli  and  Ncgri  have  described  tachycardia  following  lap- 
arotomy  and  the  extirpation  of  double  pyosalpinx.  Bonvalot  has 
published  cases  in  which,  in  consequence  of  vaginal  or  intra-uterine 
injections,  in  consequence  of  simple  examination,  and  in  conse- 
quence of  the  performance  of  version,  sudden  death  has  resulted 
from  cardiac  syncope. 

The  psychical  influences  which  proceed  from  the  female  genital 
organs  in  the  different  periods  of  sexual  life  have  also  great  signi- 
ficance for  the  organism  as  a  whole.  Manifold  impulses  both 
stimulating  and  depressing  arising  in  the  reproductive  organs  affect 
the  workings  of  the  mind.  The  maiden  at  puberty  is  affected  by 
the  knowledge  of  sexuality;  the  sexually  mature  woman,  by  the 
desire  for  sexual  satisfaction,  and  by  the  yearning  for  mother- 
hood ;  the  wife,  by  the  processes  of  pregnancy,  parturition,  and 
suckling,  or,  on  the  other  hand  by  the  distressing  consciousness  of 
sterility ;  the  woman  at  the  climacteric  period,  by  the  knowledge  of 
the  disappearance  of  her  sexual  potency.  The  mind  is  further 
sympathetically  influenced  by  the  stimulation  of  the  terminals  of 
the  sensory  nerves  in  the  genital  organs.  Through  the  increase 
of  such  stimulation,  through  its  spread  to  adjacent  nerves  and 
nerve  tracts  and  to  the  entire  nervous  system,  the  mind  is  affected, 


i8  THE  SEXUAL  LIFE  OF  WOMAN. 

directly  by  irradiation,  or  indirectly  by  vasomotor  processes  and 
spinal  hyperaesthesia. 

Psychical  manifestations  and  the  nervous  states  associated  with 
these  are  somewhat  frequently,  and  even  actual  psychoses  occa- 
sionally, encountered  in  the  various  phases  of  the  sexual  life  of 
woman,  sometimes  taking  the  form  of  violent  sexual  storms,  which 
may  indeed,  as  ordinary  menstrual  reflexes,  accompany  every  cata- 
menial  period. 

Of  great  interest  are  the  facts  which  have,  in  recent  times  espe- 
cially, been  scientifically  established,  pointing  to  a  certain  periodicity, 
to  an  undulatory  movement  of  the  general  bodily  functions  of  the 
female  organism,  dependent  upon  the  sexual  life.  The  observations 
of  Goodman,  Jacobi,  von  Ott,  Rabutcau,  Rcinl  and  Schichareff, 
have  shown  that  in  woman  the  principal  vital  processes  pursue  a 
cycle  made  up  of  stages  of  increased  and  diminished  intensity,  and 
that  this  periodicity  of  the  chief  general  processes  of  vital  activity 
finds  expression  also  in  the  functions  of  the  reproductive  organs. 
Goodman  has  compared  this  play  of  general  vital  functions  to  an 
undulatory  movement.  According  to  this  writer,  a  woman's  life 
is  passed  in  stages,  each  of  which  corresponds  in  duration  with  a 
single  menstrual  cycle.  Each  of  these  stages  exhibits  two  distinct 
halves,  in  which  the  vital  processes  are  respectively  ebbing  and 
flowing:  in  the  latter  we  see  an  increase  of  all  vital  processes,  a 
larger  heat  production,  a  rise  in  blood-pressure,  and  an  increased 
excretion  of  urea;  in  the  former  we  see,  on  the  contrary,  that  all 
these  vital  processes  display  a  diminished  intensity.  The  moment 
when  the  period  of  increased  vital  activity  is  at  an  end,  the  moment 
when  the  ebb  begins,  corresponds,  according  to  Goodman,  to  the 
commencement  of  the  catamenial  discharge. 

Goodman  sought  for  verification  of  this  undulatory  theory  of  the 
sexual  life  of  woman  in  certain  data  regarding  the  bodily  tem- 
perature and  the  blood-pressure.  A  more  extensive  research  was 
undertaken  by  Jacobi,  who,  as  the  result  of  her  observations,  came 
to  the  following  conclusions.  In  eight  cases  she  noticed  in  the  pre- 
menstrual epoch  a  rise  of  temperature  ranging  from  0.05°  C.  to 
0.44°  C.  (0.09°  F. —  0.79°  F.)  ;  and  during  the  catamenial  discharge 
a  gradual  fall  of  0.039°  €.—  0.25°  C.  (0.072°  F.— 0.45°  F.),  never 
less,  that  is  to  say,  than  a  quarter  of  a  degree  Centigrade ;  but  in  the 
majority  of  cases  the  temperature  did  not,  while  the  catamenia  lasted, 
regain  the  normal  mean.  She  further  observed  in  the  generality 
of  cases  an  increased  excretion  of  urea  during  the  premenstrual 
epoch ;  and  a  notable  fall  in  blood-pressure  during  menstruation. 

ReinVs  observations  on  healthy  women,  in  whom  menstruation 
ran  a  normal  course,  showed  that  in  the  great  majority  of  cases  in 


INTRODUCTION. 


19 


the  premenstrual  epoch  the  temperature  was  elevated  as  compared 
with  that  of  the  interval,  that  in  eleven  out  of  twelve  cases  the 
temperature  gradually  declined  during  menstruation,  to  fall  in  three- 
fourths  of  the  cases  below  the  mean  temperature  of  the  entire  inter- 
val, and  exhibiting  in  the  post-menstrual  epoch  a  still  further  depres- 
sion, giving  place,  however,  to  a  somewhat  higher  mean  temperature 
during  the  first  half  of  the  interval.  In  the  second  half  of  the  in- 
terval a  higher  mean  temperature  was  observed  than  in  the  first 
half. 

If  we  make  a  graphic  representation  of  the  mean  differences  in 
temperature  commonly  observed  throughout  the  various  stages  of 
an  entire  menstrual  cycle,  we  see  that  the  curve  does  in  fact  take  the 
form  of  a  wave.  That  drawn  by  Reinl  is  shown  in  the  following 
figure:  (Fi.G.  5.) 

I  Premenstrual  epoch 


Menstruation 


Post-menstrual  epoch 
First  half  of  the  interval 


FIG.  5. 

The  rising  portion  of.  the  wave,  the  beginning  of  the  tidal  flow, 
corresponds  to  the  second  half  of  the  interval ;  the  height  of  the  tidal 
flow,  the  crest  of  the  wave,  corresponds  to  the  premenstrual  epoch. 
As  the  flow  gives  place  to  the  ebb,  as  the  wave  begins  to  decline, 
we  come  to  the  actual  period  of  the  catamenial  discharge ;  later  in 
the  ebb  is  the  post-menstrual  epoch,  and  the  lowest  portion  of  the 
declining  wave  corresponds  to  the  first  half  of  the  interval.  Rhyth- 
mic changes  corresponding  to  those  observed  in  the  temperature 
have  been  recorded  —  at  least  in  isolated  stages  of  the  menstrual 
cycle  —  affecting  the  blood-pressure  by  Jacobi  and  by  von  Ott,  affect- 
ing the  excretion  of  urea  by  Jacobi  and  by  Rabuteau,  and  affecting 
the  pulse  by  Hennig.  It  is  evident  that  the  vital  activity  of  the 
organism  attains  its  maximum  shortly  before  menstruation ;  and 
that  with  or  immediately  before  the  appearance  of  the  catamenial 
discharge,  a  decline  of  that  activity  commences. 

Schroder,  through  his  researches  on  metabolism  during  menstrua- 
tion in  relation  to  the  condition  of  the  bodily  functions  during  this 
process,  has  established  that  immediately  before  menstruation  the 
elimination  of  nitrogen  in  the  faeces  and  the  urine  is  at  its  lowest, 
a  fact  which  indicates  that  at  this  period  of  the  menstrual  cycle 
the  disintegration  of  albumen  in  the  body  is  notably  diminished. 


20 


THE  SEXUAL  LIFE  OF  WOMAN. 


Ott  found  in  thirteen  cases  out  of  fourteen  that  at  the  be- 
ginning of  the  catamenial  discharge  or  just  before  a  considerable 
fall  in  blood-pressure  occurred,  and  that  throughout  the  flow  the 
pressure  almost  always  remained  below  the  mean,  no  rise  taking 
place  till  menstruation  was  finished ;  this  fall  in  blood-pressure  dur- 
ing menstruation  was  more  considerable  than  could  be  accounted 
for  by  the  moderate  haemorrhage.  The  same  author,  in  conjunction 
with  Schichareff,  examined  fifty-seven  healthy  women  in  respect 
of  heat-radiation,  muscular  power,  respiratory  capacity,  expiratory 
and  inspiratory  power,  and  tendon-reflexes.  He  found  that  the 
energy  of  the  functions  of  the  female  body  increased  before  the 
beginning  of  menstruation,. but  declined  with  or  immediately  before 
the  appearance  of  the  catamenial  discharge.  He  exhibited  this 
rhythmical  variation  in  the  vital  processes  by  means  of  the  follow- 
ing curve,  in  which  the  line  A  B  represents  these  physiological  varia- 
tions, whilst  on  the  abscissa  line  c  e,  the  days  of  observation  are  re- 
corded, and  the  interval  m  n  represents  the  menstrual  period. 
The  degree  of  intensity  of  the  united  functions  is  indicated  by  the 
numbers  o —  100  on  the  ordinate. 
dDO 


75 


,50 


0  \i  I  2  I  3    i  I  5    8    7\8\S    m\U\12\iS 

C 

FIG.  6. 

Still  another  point  of  view  from  which  the  influences  affecting 
the  female  organism  as  a  whole  may  be  regarded  has  very  recently 
become  apparent  in  consequence  of  the  doctrine  of  Broivn-Scqnard 
relating  to  the  internal  secretions  of  ductless  glands.  As  regards  the 
female  reproductive  glands,  which  in  consequence  of  their  structure 
must  be  referred  to  the  group  of  ductless  glands,  and  yet  owing  to 


INTRODUCTION.  21 

0 

their  secretory  function  must  be  classed  among  secreting  glands 
(so  that  the  nature  of  the  ovary  is  that  of  a  secreting  gland  without 
an  excretory  duct),  it  would  appear  that  these  glands  are  not  con- 
cerned only  with  the  specific  female  reproductive  functions  of  men- 
struation and  ovulation,  but  that  they  also  exercise  a  powerful  in- 
fluence on  the  nutritive  processes,  on  metabolism  and  haematopoiesis, 
and  on  growth  and  development  in  their  mental  as  well  as  their 
physical  relations. 

It  is  supposed  that  these  glands  under  normal  conditions  en- 
rich the  blood  with  certain  substances,  which  in  part  assist  in 
hsematopoiesis,  and  in  part  by  regulating  the  vascular  tone  in  the 
various  organs  are  concerned  in  the  normal  processes  of  assimilation 
and  general  metabolism.  According  to  Etienne  and  Demange, 
ovariin  possesses  an  oxidising  power  similar  to  that  possessed  by 
spermin.  Thus  it  becomes  easy  to  understand  how  disturbances  in 
the  functions  of  the  ovaries  give  rise  to  disturbances  in  the 
processes  of  general  metabolism  and  of  assimilation.  Some  go 
even  further,  though  in  doing  so  they  leave  the  ground  of  assured 
fact,  suggesting  that  the  ovary  in  certain  circumstances  pro- 
duces toxins,  or  that  the  normal  ovary  possesses  an  antitoxic  func- 
tion, and  speaking  of  an  occasional  ovarian  auto-intoxication  of  the 
body  or  of  a  menstrual  intoxication.  Thus,  chlorosis  is  by  some 
regarded  as  a  disturbance  of  haematopoiesis,  dependent  on  an  ab- 
normal condition  of  the  female  reproductive  organs  during  the 
period  of  development,  and  referable  to  a  disturbance  of  the  internal 
secretion  of  the  ovaries  (Charrin,  von  Noorden,  Salmon,  Etienne, 
and  Demange}.  And  it  is  now  generally  assumed,  the  assumption 
being  based  on  the  observations  recently  made  concerning  the  or- 
ganotherapeutic  employment  of  the  chemical  constituents  of  the 
ovary,  that  many  of  the  disorders,  and  especially  those  connected 
with  the  vasomotor  system,  common  during  the  climacteric  period, 
are  dependent  on  the  deficiency  of  the  products  of  the  internal 
secretion  of  the  ovary  that  accompanies  the  cessation  of  the  menses. 

Recent  experimental  investigations  on  this  subject  have  shown 
that  the  interconnection  between  the  female  genital  organs  and  the 
organism  as'  a  whole,  between  the  functions  of  the  reproductive 
organs  and  the  functions  of  other  organs,  does  not  depend  on 
nervous  influences  only,  but  that  in  this  interconnection  the  blood 
vascular  system  and  the  lymphatic  vascular  system  also  play  their 
parts.  Goltz  has  proved  by  actual  experiment  that  the  nervous  in- 
fluence on  menstruation  and  ovulation  is  not  the  only  determinant. 
In  a  bitch,  he  divided  the  spinal  cord  at  the  level  of  the  first  lumbar 
vertebra,  and  observed,  as  soon  as  the  animal  had  recovered  from  the 
operation,  the  appearance  of  the  usual  signs  of  heat ;  the  bitch  was 


22  THE  SEXUAL  LIFE  OF  WOMAN. 

impregnated,  and  gave  birth  to  one  living  and  two  dead  puppies; 
Jactation  and  sucking  took  place  as  in  a  normal  animal.  When  the 
bitch  was  killed  and  the  body  examined  it  was  found  that  no  reunion 
had  taken  place  in  the  severed  spinal  cord.  The  experiments  of 
Halban  gave  similar  results.  He  found  that  in  apes,  if  the  ovaries 
are  removed  from  their  normal  situation  and  successfully  trans- 
planted to  some  region  remote  from  the  genital  organs,  the  animals 
remain  capable  of  menstruating.  But  if  the  ovaries,  which  have 
been  transplanted  beneath  the  skin  or  beneath  the  peritoneum,  are 
subsequently  entirely  removed,  menstruation,  which  has  continued 
regularly  after  the  first  operation,  ceases  altogether  after  the  second. 
It  follows  from  these  experiments  that  the  cessation  of  the  menstrual 
process  may  be  considered  to  be  brought  about  through  the  inter- 
mediation of  the  lymphatic  or  blood-vascular  system,  by  the  ab- 
sence of  a  kind  of  internal  secretion. 

Loewy  and  Richter  have  further  proved  by  experiment  that  in 
spayed  bitches  the  consumption  of  nitrogen  is  less  by  about  20 
per  cent,  and  the  entire  gaseous  interchange  less  by  about  9  per 
cent.,  as  compared  with  what  takes  place  in  normal  animals,  and 
that  this  change  in  respiratory  metabolism  lasts  for  a  long  time 
after  the  oophorectomy,  for  as  much  as  nine  to  twelve  months.  If 
dried  ovaries  are  given  to  such  animals  in  their  food,  the  gaseous 
interchange  rises  to  the  former  level  and  even  higher. 

The  undulatory  movement  of  the  vital  processes  in  woman  is 
apparently  in  some  way  dependent  on  ovulation,  though  the  nature 
of  the  connection  has  not  hitherto  been  fully  elucidated.  This  view 
is  confirmed  by  the  fact  that  no  such  rhythmic  variation  in  the 
bodily  functions  can  be  detected  either  in  girls  under  thirteen  years 
of  age,  or  in  women  from  fifty-eight  to  eighty  years  of  age  in 
whom  menstrual  activity  has  entirely  disappeared.  The  menstrual 
rhythm  begins  at  puberty  and  ends  when  ovulation  ceases. 

A  further  contribution  to  the  doctrine  of  the  undulatory  move- 
ment of  the  vital  processes  in  wwnan  is  to  be  found  in  my  own 
observations  that  pathological  symptoms  which  have  become  mani- 
fest before  and  at  the  time  of  the  first  onset  of  menstruation,  and 
have  given  but  little  trouble  throughout  the  period  of  developed 
and  regular  sexual  activity,  are  apt  when  menstruation  ceases  to 
recrudesce,  and  to  become  as  prominent  as  they  were  at  the  com- 
mencement of  the  sexual  life.  Women  who  at  the  time  of  puberty 
suffered  from  cardiac  troubles,  from  digestive  disturbances,  or  from 
various  forms  of  nervous  irritation,  and  in  whom  as  they  grew  up 
these  disorders  passed  more  or  less  into  abeyance,  are  apt  at  the 
climacteric  period  to  exhibit,  as  I  have  frequently  been  able  to 
observe,  a  violent  return  of  these  symptoms,  in  the  form,  as  the 


INTRODUCTION.  23 

case  may  be,  of  tachycardia,  of  dyspeptic  troubles,  or  of  psycho- 
neuroses.  In  this  connection  we  may  mention  an  observation  of 
Pot ain's,  who  distinguishes  a  peculiar  form  of  chorosis,  occurring  in 
individuals  of  delicate  constitution,  which,  though  apparently  cured, 
reappears  at  the  menopause. 

Related  to  the  sexual  life  of  woman  is  another  attribute,  one  in- 
timately connected  with  the  idea  of  the  female  sex,  and  one  which 
since  the  primeval  days  of  humanity  has  filled  men  with  delight  and 
poets  with  inspiration  —  the  attribute  of  beauty. 

The  beauty  of  woman,  a  prominent  secondary  sexual  character, 
makes  its  first  appearance  at  puberty,  when  the  girl's  form,  hitherto 
undifferentiated  in  its  external  bodily  configuration,  begins  to  as- 
sume a  soft  and  rounded  appearance,  when  the  features  become 
regular,  the  breasts  enlarge,  and  the  pubic  hair  begins  to  grow  — 
when,  in  short,  to  the  primary  sexual  characters  already  existing, 
the  secondary  sexual  characters  are  superadded. 

Feminine  beauty  continues  to  increase  until  the  attainment  of 
sexual  maturity.  In  her  third  decade  woman  arrives  at  the  acme 
of  her  sexual  life  and  at  the  same  time  attains  the  perfection  of  her 
beauty. 

The  ensuing  sexual  phases,  pregnancy,  parturition,  and  lactation, 
entail  a  decline  in  beauty,  not  rapid  indeed,  but  advancing  gradually, 
with  the  slow  yet  sure-footed  pace  of  time.  The  organic  revolutions 
accompanying  these  processes  leave  traces  recorded  upon  the  sur- 
face of  the  body  in  conspicuous  and  indelible  characters.  The  ill- 
nesses, also,  which  so  often  accompany  the  fulfilment  of  sexual 
functions,  in  injuring  health  impair  also  beauty. 

A  woman  who  has  given  birth  to  and  nursed  an  infant  begins  to 
lay  on  fat,  and  this  tendency  to  obesity  becomes  more  pronounced 
as  the  climacteric  period  approaches.  The  breasts  become  inelastic 
and  pendent,  the  abdomen  becomes  ungracefully  prominent ;  the 
tonicity  of  the  entire  organism  gradually  declines,  and,  in  conse- 
quence of  the  loss  of  elasticity  in  the  subcutaneous  cellular  tissue, 
the  dreaded  wrinkles  make  their  appearance  and  the  features  be- 
come wizened.  Beauty  is  a  thing  of  the  past.  With  the  cessation 
of  the  sexual  life  the  external  secondary  sexual  characters  disappear, 
and  the  old  woman  is  even  farther  removed  than  the  old  man  from 
our  conception  of  beauty. 

As  Mantegasza  insists,  the  beauties  peculiar  to  women  are  one  and 
all  sexual;  they  depend,  that  is  to  say,  upon  the  peculiar. functions 
that  nature  has  allotted  to  woman  in  the  great  mystery  of  procrea- 
tion. One  of  the  most  vivid  and  poetical  descriptions  in  ancient  or 
modern  literature  of  these  secondary  sexual  characters  on  which 
feminine  beauty  depends  is  to  be  found  in  the  Song  of  Solomon. 


THE  SEXUAL  LIFE  OF  WOMAN. 


In  the  following  figure  (FiG.  7)  the  curve  of  beauty  of  woman 
is  given  as  drawn  up  by  Stratz.  In  one  case  it  may  rise  very 
quickly,  to  decline  with  equal  quickness  —  the  so-called  beaute  du 
diable;16  in  other  cases,  again,  the  curve  rises  very  slowly,  and 
declines  also  very  slowly,  the  culmination  of  the  curve  being  in 
this  case  attained  later,  and  when  attained  being  absolutely  higher, 
than  in  the  case  of  the  steeper  curve. 

The  age  at  which  the  maximum  of  beauty  is  attained  is  a  very 
variable  one.  In  the  southern  races  this  often  occurs  as  early  as 
the  fourteenth  or  fifteenth  year  of  life;  but  in  the  peoples  of  the 
Teutonic  stock,  Germans,  Dutch,  Scandinavians,  and  English,  not 
as  a  rule  before  the  twentieth  year,  and  it  may  be  even  later.  Stratz 


FIG.  7. 

has  known  cases  in  which  women  did  not  attain  the  prime  of 
their  beauty  until  the  thirtieth  and  even  the  thirty-third  year.  The 
same  author,  a  most  competent  authority  as  regards  the  subject 
of  feminine  beauty,  affirms  that  a  beautiful  woman  is  most  beauti- 
ful when  the  period  of  maximum  beauty  coincides  in  her  case  with 
the  first  month  of  her  first  pregnancy.  With  the  commencement 
of  pregnancy  the  processes  of  nutrition  are  accelerated,  all  the 
tissues  are  tensely  filled,  the  skin  is  more  delicately  and  at  the  same 
time  more  brightly  tinted  owing  to  the  greater  activity  of  the  cir- 
culation, the  breasts  become  firmer  and  more  elastic.  Thus  the 
attractive  characteristics  of  beauty  at  its  fullest  maturity  become 

18  Beauty  of  the  devil. 


INTRODUCTION.  25 

enhanced,  but  for  a  short  time  only,  since  the  enlargement  of  the 
abdomen  in  the  further  course  of  pregnancy  impairs  the  harmony 
of  the  figure.  Finally  we  must  point  out,  before  dismissing  this 
subject,  that  women  of  the  so-called  better  classes  arrive  as  a  rule 
at  maturity  later,-  and  remain  beautiful  for  a  longer  period,  than 
women  of  the  working  classes. 

The  degree  to  which  the  female  organism  as  a  whole  is  in- 
fluenced by  the  processes  of  the  sexual  life  that  occur  in  the  genital 
organ  depends  upon  many  of  the  characteristics  that  combine  to 
make  up  the  individuality.  Inherited  characteristics,  tempera- 
ment, and  race,  play  a  great  part  in  this  connection;  and  not  less 
important  than  these  are  the  social  conditions,  the  environment,  in 
which  the  women  under  consideration,  pass  their  life.  Thus, 
among  women  belonging  to  the  poorer,  labouring  classes,  the  reflex 
manifestations  in  other  organs  dependent  upon  the  processes  of 
the  genital  organs  are  less  frequent  and  less  intense  than  among 
.women  belonging  to  the  well-to-do  strata  of  society  and  to  the 
cultured  classes;  less  also  in  the  country  than  in  large  towns.  In 
phlegmatic  individuals,  such  manifestations  exhibit  less  intensity 
than  in  those  of  an  active,  ardent  temperament;  they  are  less  fre- 
quent in  persons  with  a  powerful  constitution  than  in  those  en- 
dowed by  inheritance  with  an  unstable  nervous  system.  Finally, 
they  are  less  often  encountered  among  families  whose  upbringing 
has  aimed  at  hardening  the  constitution  and  at  inculcating  the 
control  of  instinctive  impulses,  than  among  those  in  whom  from 
early  childhood  sensibility  and  impulsiveness  have  been  given  a 
loose  rein. 

Extremely  variable  also  are  the  sympathetic  disturbances  and 
morbid  states  which  depend  on  the  processes  of  the  sexual  life  of 
woman.  "  Le  cri  de  1'organe  souffrant  ne  vient  pas  de  1'uterus, 
mais  de  tout  1'organisme,"  17  says  Courly.  And  a  large  number  of 
isolated  observations  has  shown  how  complex  are  the  relations 
between  the  healthy  and  unhealthy  female  genital  Organs  and  the 
other  organs  of  the  body  as  well  as  the  organism  as  a  whole. 
Precise  and  incontestable  proofs  exist  of  such  relations  between 
the  female  genital  organs  and  morbid  changes  in  the  eye  and  ear, 
the  skin,  the  respiratory  organs,  and  the  vascular  and  nervous 
systems. 

The  influence  exercised  by  the  reproductive  system  on  the  gen- 
eral vital  processes  of  woman  is  indicated  also  by  the  general 
statistics  of  mortality  and  the  incidence  of  disease.  Mortality  in 
women,  the  earliest  years  of  childhood  being  left  out  of  considera- 

17 "The  cry  of  the  suffering  organ  comes  not  from  the  uterus  but  from  the 
entire  organism." 


26  THE  SEXUAL  LIFE  OF  WOMAN. 

tion,  is  at  its  highest  precisely  during  the  great  sexual  epochs, 
namely  at  the  time  of  puberty,  during  pregnancy,  during  the  puer- 
perium,  and  at  the  climacteric  period.  The  complete  performance 
of  the  reproductive  functions  entails  a  higher  proportion  of  ill- 
nesses and  death;  and  statistical  records  show  that  the  mortality 
of  married  women  between  twenty  and  forty  years  of  age,  during 
the  period,  that  is  to  say,  in  which  in  consequence  of  marriage 
they  fulfil  the  duties  of  sexual  intercourse  and  procreation,  and  are 
exposed  to  the  dangers  connected  with  these  sexual  acts,  is  much 
higher  than  the  mortality  of  unmarried  women  of  corresponding 
ages.  Infection  with  the  gonococcus  and  with  the  virus  of  syphilis, 
chronic  salpingitis,  metritis,  and  parametritis,  the  manifold  dis- 
eases of  pregnancy,  the  diseases  of  the  puerperium,  the  various  dis- 
placements of  the  uterus,  osteomalacia  —  all  these  are  pathological 
states  the  dependence  of  which  upon  the  sexual  life  of  the  married 
or  at  any  rate  sexually  active  woman  is  indisputable.  But  the 
complete  renunciation  of  sexual  activity  appears  also  to  exercise 
an  injurious  influence  on  the  health,  and  to  give  rise  or  at  least 
predispose  to  morbid  manifestations.  Hysteria,  for  instance, 
chlorosis,  uterine  myomata,  and  various  neuroses,  have  long  been 
supposed  to  depend  in  part  upon  such  renunciation,  though  the 
causal  connection  cannot  be  regarded  as  yet  fully  established. 

Especially  true  as  regards  woman,  indeed,  is  that  which  Ribbing 
says  concerning  the  sexual  life  in  general:  "  Since  all  human  life 
and  being  has  its  origin  in  sexual  relations,  these  sexual  relations 
may  be  regarded  as  the  heart  of  humanity.  We  may  work  day  and 
night  for  the  good  of  humanity,  we  may  sacrifice  for  that  good 
our  time  and  our  blood,  but  all  this  work  and  all  this  sacrifice 
appear  to  me  to  remain  useless  if  we  neglect  and  despise  the  sexual 
life,  the  eternally  self-renewing  elementary  school  of  true  altruism.'' 

From  the  vital  phase  in  which,  marked  by  the  visible  manifesta- 
tions of  puberty  and  by  the  first  appearance  of  menstruation, 
ovulation  is  assumed  to  begin,  the  sexual  life  of  woman  continues 
to  the  period  of  life  in  which,  marked  by  the  climacteric  cessation 
of  menstruation,  ovulation  also  ceases.  The  total  duration  of  this 
sexual  period  in  woman's  life  is  usually  about  thirty  years ;  but  it  is 
subject  to  great  variations,  from  six  to  forty-six  years  according 
to  the  available  statistics,  these  variations  depending  upon  climate, 
race,  constitution,  and  the  sexual  activity  of  the  person  under 
consideration. 

The  duration  and  the  intensity  of  the  sexual  life  of  woman  de- 
pends upon  a  series  of  external  conditions  affecting  the  individual, 
but  especially  upon  the  inherited  predispositions,  upon  the  consti- 
tutional conditions,  upon  the  varying  vital  power  of  the  individual. 


INTRODUCTION.  27 

My  own  observations  have  led  me  to  formulate,  as  a  general  law, 
that  the  earlier  a  woman  (climatic  and  social  conditions  being 
similar  in  the  cases  under  comparison)  arrives  at  puberty,  the 
earlier,  that  is  to  say,  that  menstrutation  first  makes  its  appearance, 
the  greater  will  be  the  intensity  and  the  longer  the  duration  of 
sexual  activity,  the  more  will  the  woman  in  question  be  predisposed 
to  bear  many  children,  the  more  powerfully  will  the  sexual  im- 
pulse manifest  itself  in  her,  and  the  later  will  the  menopause 
appear.  It  seems  that  in  such  women  a  more  intense  vitality  ani- 
mates the  reproductive  system,  bringing  about  an  earlier  ripening 
of  ova,  a  more  favorable  predisposition  on  the  part  of  these  ova 
to  fertilization  by  the  spermatozoa,  a  livelier  manifestation  of 
sexual  sensibility,  and  a  longer  dviration  of  ovarian  functional 
activity. 

My  general  views  on  this  subject  are  embodied  in  the  following 
propositions: 

1.  The  duration  of  sexual  activity  is  less  in  the  women  belong- 
ing to  the  countries  of  southern  Europe  than  in  those  belonging 
to  the  countries  of  northern   Europe.     It   would  appear  that  in 
those  climates  in  which  ovulation  begins  sooner  and  menstruation 
first  appears  at  an  earlier  age,  the  menopause  also  appears  earlier; 
but  that,  on  the  contrary,  in  those  climates  in  which  puberty  is 
late  in  its  appearance,  the  decline  of  sexual  activity  is  similarly 
postponed. 

2.  Women    in    our   mid-European    climates,    in    whom    puberty 
appears  at  an  early  age,  the  first  menstruation  occurring  between 
the  ages  of  thirteen  and  sixteen,  exhibit  a  more  prolonged  du.a- 
tion  of  the  sexual  life,  of  menstrual  functional  activity,  than  women 
in  whom  menstruation  begins  late,  between  the  ages  of  seventeen 
and  twenty.     Extremely  early   appearance   of  the   first   menstrua- 
tion—  so  early  as  to  be  altogether  abnormal  —  has,  however,  the 
same  significance  as  abnormally  late  onset  of  menstruation;  both 
indicate  that  the  sexual  life  will  be  of  short  duration. 

3.  Women  whose  reproductive  organs  have  been  the  seat  of  a 
sufficient   amount   of   functional   activity,   who   have   had    frequent 
sexual  intercourse,  have  given  birth  to  several  children,  and  have 
themselves  suckled  their  children,  have  a  sexual  life  of  longer  dura- 
tion, as  manifested  by  the  continuance  of  menstruation,  than  women 
whose  circumstances  have  been  just  the  opposite  of  these,  unmar- 
ried women,  for  instance,  women  early  widowed,  and  barren  women. 
Sexual  intercourse   at  a  very  early  age,  however,  accelerates  the 
onset  of  the  climacteric  period  and  the  termination  of  the  sexual 
life.     The  same  result  follows  severe  or  too  frequent  confinements. 

4.  The  sexual  life  has  a  shorter  duration  in  the  women  of  the 
laboring  classes  and  belonging  to  the  lower  strata  of  social  life,  as 


28  THE  SEXUAL  LIFE  OF  WOMAN. 

compared  with  upper  class  and  well-to-do  women.  Bodily  hard- 
ships, grief,  and  anxiety  also  hasten  the  onset  of  sexual  death. 

5.  Women  who  are  weakly  and  always  ailing  have  a  shorter 
sexual  life  than  women  who  are  powerfully  built  and  always  in 
good  health.  When  irregularities  and  disorders  have  appeared  in 
the  various  sexual  phases,  the  decline  of  sexual  activity  occurs 
earlier  than  in  women  whose  functions  have  in  this  respect  been 
normal.  Certain  constitutional  conditions,  such  as  extreme  obesity, 
certain  acute  diseases,  such  as  typhoid  fever,  malaria,  and  cholera, 
and  certain  diseases  of  the  uterus  and  its  annexa,  chronic  inflam- 
matory conditions  for  instance,  bring  about  a  notable  shortening  of 
the  duration  of  the  sexual  life. 

In  500  cases  that  have  come  under  my  own  observation,  the 
women  concerned  belonging  to  very  various  nationalities,  the  dura- 
tion of  the  sexual  life,  as  witnessed  by  the  continuance  of  menstrua- 
tion, was  as  follows: 

Menstruation  continued  for: 


6  years 
7  years 
9  years 
II  years 
15  years 
16  years 
17  years 
18  years 
19  years 
20  years 
21  years 

in 

in 
in 

in 

in 

in 

in 
in 

in 

in 
in 

I 
I 
2 

4 

6 
8 

12 

15 

9 

6 

18 

woman, 
woman, 
women, 
women, 
women, 
women, 
women, 
women, 
women, 
women, 
women. 

22 

23 
24 

25 
26 
27 
28 
29 
30 
3i 
32 

years 
years 
years 
years 
years 
years 
years 
years 
years 
years 
years 

in  20 
in  24 
in  18 
in  16 
in  25 
in  26 
in  29 
in  36 
in  22 
in  32 
in  49 

women, 
women, 
women, 
women, 
women, 
women, 
women, 
women, 
women, 
women, 
women. 

33 
34 
35 
36 

37 
3« 
39 
40 

43 
45 
46 

years 
years 
years 
years 
years 
years 
years 
years 
years 
years 
years 

in  31 
in  26 
in  12 
in  12 
in  10 
in     8 
in    6 
in    2 
in    2 
in     I 
in     I 

women. 
women. 
women, 
women, 
women, 
women, 
women, 
women, 
women, 
woman, 
woman. 

Thus  we  see  that  the  duration  of  the  sexual  life  varies  from  6  to 
46  years.  The  most  frequent  duration  is  one  of  32  years,  next  to 
this  one  of  29,  next  again,  31,  33,  and  37  years,  respectively.  In 
6  women  only  did  the  duration  of  the  sexual  life  exceed  40  years, 
and  ill  4  only  was  it  less  than  n  years.  In  half  of  all  my  cases  the 
duration  of  the  sexual  life  was  between  27  and  34  years,  and  from 
these  figures  we  obtain  an  average  duration  of  about  30  years. 

For  North  Germany,  Krieger  gives  data  from  which  it  appears 
that  in  this  region  the  average  duration  of  the  sexual  life  is  30.49 
years.  In  more  than  half  of  the  722  cases  recorded  by  this  writer 
the  duration  was  between  31  and  37  years.  In  isolated  cases  the 
duration  was  very  short,  not  exceeding  8,  9,  or  10  years,  or,  on  the 
other  hand,  as  long  as  47  years ;  whilst  the  number  of  cases  in- 
creased fairly  regularly  up  to  the  duration  of  34  years,  and  there- 
after again  diminished. 

As  regards  Austria,  Sznkits  has  collected  information  in  the 
case  of  269  women,  and  found,  in  these,  that  the  duration  of  the 
sexual  life  varied  from  12  to  45  years.  The  average  duration  was 


INTRODUCTION. 


29.16  years;  in  more  than  half  of  the  women,  the  period 
activity  lasted  from  21  to  30  years;  the  shortest  period 
was  12  years,  the  longest  45  years. 
The  period  of  sexual  activity  lasted : 


of  sexual 
observed 


12  years 
14  years 
15  years 
17  years 
19  years 
20  years 
21  years 
22  years 
23  years 
24  years 

in 
in 
in 
in 
in 
in 
in 
in 
in 
in 

2 

I 
2 

3 
3 

17 

10 

7 
5 

17 

women. 
woman, 
women, 
women, 
women, 
women, 
women, 
women, 
women, 
women. 

25 
26 
27 
28 
29 
30 
31 
32 
33 
34 

years 
years 
years 
years 
years 
years 
years 
years 
years 
years 

in    7 
in  13 
in    5 
in  26 
in  18 
in  17 
in     8 
in    8 
in  13 
in    8 

women, 
women, 
women, 
women, 
women, 
women, 
women, 
women, 
women, 
women. 

35 
36 
37 
38 
39 
40 

42 

43 
44 

45 

years 
years 
years 
years 
years 
years 
years 
years 
years 
years 

in 
in 
in 
in 
in 
in 
in 
in 
in 
in 

18  women. 
19  women. 
14  women. 
9  women. 
8  women. 
I  woman. 
I  woman. 
I  woman. 
2  women. 
2  women. 

In  Poland,  according  to  Raciborski,  the  duration  of  sexual  activity 
is  in  Jewesses  23  years,  but  in  women  of  Slavonic  blood  31  years. 

In  France,  according  to  Courty  and  Puecli,  the  usual  duration  of 
the  sexual  life  is  from  28  to  30  years. 

According  to  Puech,  among  10  women  menstrual  activity  lasted: 


33 
35 


years  m  2  women, 
years  in  I  woman. 


36 
39 


years  in  2  women, 
vears  in  2  women. 


43     years  in  2  women. 
44^2  years  in  I  woman. 


Brierre  de  Boismont  gives  the  following  particulars  of  the  dura- 
tion of  menstrual  activity  in  178  Frenchwomen: 


5  years 

m 

I 

woman. 

23 

years 

m  12 

women. 

34 

years 

in 

7  women. 

6  years 

in 

I 

woman. 

24 

years 

in    8 

women. 

35 

years 

in 

5  women. 

8  years 

in 

I 

woman. 

25 

years 

in    8 

women. 

36 

years 

in 

10  women. 

II  years 

in 

I 

woman. 

26 

years 

in  II 

women. 

37 

years 

in 

6  women. 

16  years 

in 

4 

women. 

27 

years 

in    7 

women. 

38 

years 

in 

5  women. 

17  years 

in 

4 

women. 

28 

years 

in    6 

women. 

39 

years 

in 

2  women. 

18  years 

in 

I 

woman. 

29 

years 

in    7 

women. 

40 

years 

in 

7  women. 

19  years 

in 

3 

women. 

30 

years 

m  13 

women. 

4i 

years 

in 

i  woman. 

20  years 

in 

3 

women. 

3i 

years 

in  13 

women. 

42 

years 

in 

3  women. 

21  years 

in 

4 

women. 

32 

years 

in     9 

women. 

44 

years 

in 

2  women. 

22  years 

in 

3 

women. 

33 

years 

in    9 

women. 

48 

years 

in 

I  woman. 

For  England,  Tilt  gives  the  mean  duration  of  menstrual  activity, 
as  observed  in  500  women,  as  31.21  years;  it  varies  between  II 
and  47  years ;  there  are  more  cases  with  a  period  of  34  years 
than  with  any  other  integral  number  of  years.  Tilt  found  the  dura- 
tion to  be : 


II  years 

in 

I 

woman. 

25 

years 

in  22 

women. 

37 

years 

in  16 

women. 

13  years 

in 

I 

woman. 

26 

years 

in  ii 

women. 

38 

years 

in  15 

women. 

15  years 

in 

3 

women. 

27 

years 

in  25 

women. 

39 

years 

in  15 

women. 

16  years 

in 

I 

woman. 

28 

years 

in  29 

women. 

40 

years 

in    6 

women. 

17  years 

in 

2 

women. 

29 

years 

in  35 

women. 

4i 

years 

in    4 

women. 

18  years 

in 

4 

women. 

30 

years 

in  36 

women. 

42 

years 

in     7 

women. 

19  years 

m 

I 

woman. 

31 

years 

in  33 

women. 

43 

years 

in    5 

women. 

20  years 

in 

3 

women. 

32 

years 

in  38 

women. 

44 

years 

in    3 

women. 

21  years 

in 

6 

women. 

33 

years 

in  35 

women. 

45 

years 

in     I 

woman. 

22  years 

in 

ii 

women. 

34 

years 

in  49 

women. 

46 

years 

in     I 

woman. 

23  years 

in 

ir 

women. 

35 

years 

in  33 

women. 

47 

years 

in     3 

women. 

24  years 

in 

10 

women. 

36 

years 

in  26 

women. 

THE  SEXUAL  LIFE  OF  WOMAN. 


For  London  the  average  figure  is  34  years ;  for  Paris,  30  years ; 
for  Vienna,  29  years;  and  for  Berlin,  34  years. 

From  the  data  of  various  observers  obtained  from  diverse  na- 
tionalities, the  following  table  has  been  compiled,  exhibiting  the 
mean  duration  of  the  sexual  life: 

Comparative  Table  Showing  the  Duration  of  the  Sexual  Life  in 
Various  Nationalities. 


Germany. 

Austria. 

France. 

England. 

Denmark. 

Norway. 

Russia. 

Number  of 
Cases.. 

722 

265 

178 

5«o 

312 

39i 

too 

Mean  duration 
of  menstrual 
activity,     in 

it  8 

Observers' 
names.  . 

Krieger, 
L.  Mayer. 

Szukits. 

Brierre  de 
Boismont. 

Whitehead. 

Hannover. 

Faye  & 
Vogt. 

Lieven. 

In  the  temperate  zone  the  sexual  life  of  woman  lasts  longer  than 
in  the  colder  and  subarctic  regions.  Still  more  favorable  is  the  con- 
trast between  the  temperate  zone  and  the  countries  of  the  tropics,  in 
which  the  duration  of  the  period  of  menstrual  activity  is  limited  to 
eighteen  or  twenty  years.  According  to  some  isolated  observations 
the  duration  of  sexual  activity  in  Arabian  women  in  Africa  was  as 
little  as  nine  years. 

A  certain  influence  on  the  duration  of  the  sexual  life  is  exercised 
by  the  commencement  of  menstruation  at  an  earlier  or  later  age  than 
the  average.  The  total  duration  of  menstrual  activity  is  more 
variable  in  women  who  begin  to  menstruate  early  than  in  women 
who  begin  to  menstruate  late,  in  whom  the  duration  of  the  sexual 
life  is  a  more  regular  one.  In  those  women  who  begin  to  men- 
struate early  the  mean  duration  of  the  sexual  life  is  about  thirty- 
three  years,  in  those  who  begin  to  menstruate  late  it  is  about  twenty- 
seven  years. 

The  following  data,  based  on  the  observation  of  250  cases,  are 
published  by  W .  Guy,  regarding  the  duration  of  the  sexual  life, 
that  is  to  say  of  menstrual  activity,  in  women  beginning  to  men- 
struate early  and  those  beginning  to  menstruate  late,  respectively : 

Menstruation  began  Duration  of  the  sexual  life. 

In      5  cases  in  the    8th  to  the  loth  year Averaging  36.60  years. 

In     70  cases  in  the  nth  to  the  I3th  year Averaging  33.65  years. 

In  no  cases  in  the  I4th  to  the  i6th  year Averaging  30.85  years. 

In    56  cases  in  the  -I7th  to  the  igth  year Averaging  28.35  years. 

In      9  cases  in  the  2oth  year  or  later Averaging  20.45  years. 


INTRODUCTION. 


A  further  analysis  of  these  250  cases  is  given  by  Guy  in  the  fol- 
lowing table : 

,  Average  age  at  -which        Duration  of 

menstruation  ceased,  menstrual 

First  appearance  of  menstruation.  in  years.  activity. 

In     i  case  in  the     8th  year 42       34  years. 

In     2  cases  in  the     9th  year 46 37  years. 

In     2  cases  in  the  loth  year 47       37  years. 

In  10  cases  in  the  nth  year 47. 10 56.10  years. 

In  29  cases  in  the  I2th  year 45-34 33-34  years. 

In  31  cases  in  the  i3th  year 46.16 33. 16  years. 

In  39  cases  in  the  I4th  year 45-33 31-33  years. 

In  40  cases  in  the  I5th  year 46.30 31.30  years. 

In  41  cases  in  the  i6th  year 46. 14 30. 14  years. 

In  26  cases  in  the  ijth  year -45. 18 28. 18  years. 

In  19  cases  in  the  iSth  year 46.87 28.87  years. 

In  il  cases  in  the  igth  year 46. 18 27. 18  years. 

In     5  cases  in  the  2oth  year ; 40.80 20.80  years. 

In    3  cases  in  the  2ist   year 41 .66 20.66  years. 

In     i  case  in  the  23d    year 41       18  years. 

Hannover  also  gives  data  respecting  the  relation  between  -the  dura- 
tion of  menstrual  activity  and  the  early  or  late  appearance  of  men- 
struation. These  data  are  tabulated  as  follows: 

Average  age  at  ivhich        Duration  of 
menstruation  ceased,  menstrual 

in  years.  activity. 

47.80 35.80  years. 

45-89 32.89  years. 

44.08 30.98  years. 

45-56 30. 56  years. 

44-13 29.13  years. 

43-QO 26.00  years. 

44-96 26.96  years. 

44-79 25.79  years. 

45-36. 25.36  years. 

44. 10 23 . 10  years. 

43-50 21 . 50  years. 

44-33 21.33  years. 

«••  39-5° 15.50  years. 


First  appearance  of  menstruation. 

In     5  cases  in  the  I2th  year 

In  10  cases  in  the  I3th  year 

In  .50  cases  in  the  I4th  year 

In  34  cases  in  the  I5th  year 

In  38  cases  in  the  i6th  year 

In  36  cases  in  the  I7th  year 

In  49  cases  in  the  i8th  year 

In  33  cases  in  the  igth  year 

In  38  cases  in  the  2oth  year 

In  10  cases  in  the  2ist  year 

In     4  cases  in  the  22d    year 

In     3  cases  in  the  23d    year 

In    4  cases  in  the  24th  year 


Totals :  In  412  cases  the  average  age  at  the  menopause  was 
44.82,  and  the  average  duration  of  menstrual  activity  was  27.973 
years. 

From  the  tables  of  L.  Mayer,  Krieger  has  instituted  a  compari- 
son between  the  duration  of  menstrual  activity  in  101  women  who 
began  to  menstruate  early  and  180  women  who  began  to  menstruate 
late,  finding  in  the  case  of  the  former  a  mean  duration  of  33.673 
years,  and  in  the  case  of  the  latter  a  mean  duration  of  27.344 
years,  showing  therefore  a  sexual  life  longer  on  an  average  by  6.429 
years  in  those  in  whom  puberty  was  early  as  compared  with  those 
in  whom  puberty  was  late. 

From  the  tables  of  Tilt,  based  on  the  observation  of  164  cases, 
76  women  in  whom  menstruation  appeared  early  and  88  in  whom 


32  THE  SEXUAL  LIFE  OF  WOMAN. 

it  appeared  late,  we  learn  that  among  the  former  the  shortest  dura- 
tion of  menstrual  activity  was  18  years,  among  the  latter  12 
years ;  among  the  former  the  longest  duration  was  37  years,  among 
the  latter  only  33.  The  majority  of  those  who  began  to  menstruate 
early  continued  to  menstruate  for  28,  31,  32,  33,  34,  35,  36,  38,  or 
39  years ;  those  who  began  to  menstruate  late,  for  23,  27,  28,  30, 
or  31  years.  The  mean  duration  of  the  sexual  life  in  those  who 
began  to  menstruate  early  was  33.66  years;  in  those  who  began 
to  menstruate  late  it  was  28.28  years.  Since  the  average  duration 
of  the  menstrual  function  is  given  by  Tilt  as  31.33  years,  those  who 
began  to  menstruate  early  exceeded  this  average  by  2.33  years, 
while  those  who  began  to  menstruate  late  exhibited  a  duration  of 
menstrual  activity  of  at  least  three  years  less  than  the  average. 

In  addition  to  climate,  nationality,  and  the  age  at  which  menstrua- 
tion begins,  the  sexual  activity  of  women  also  exercises  an  influ- 
ence on  the  duration  of  their  sexual  life,  and  of  especial  import- 
ance in  this  connection  are  the  number  of  children  born,  and  exer- 
cise or  neglect  of  the  function  of  lactation.  From  my  own  observ- 
vations  on  this  matter  it  appears,  that  in  women  who  are  healthy 
and  of  powerful  constitution,  whose  reproductive  organs  have  been 
sufficiently  exercised,  who  have  given  birth  to  several  children 
and  have  suckled  these  children  themselves,  the  duration  of  men- 
strual activity  is  in  general  notably  longer  than  in  women  whose 
circumstances  have  been  just  the  opposite  in  these  respects.  Among 
the  women  in  my  own  series  of  cases  in  whom  menstrual  activity 
lasted  longest,  of  the  177  women  in  whom  menstruation  ceased  be- 
tween the  forty-fifth  and  the  fiftieth"  year  of  life,  I  only  was  un- 
married, 2  were  married  but  childless,  32  married  with  I  or  2 
children  only,  and  142  married  and  with  more  than  2  children;  of 
the  89  women  in  whom  menstruation  ceased  between  the  fiftieth 
and  the  fifty-fifth  year  of  life,  none  were  either  unmarried  or  child- 
less, 19  were  married  with  I  or  2  children,  17  married  and  with 
more  than  2  children ;  of  the  17  women  in  whom  menstruation 
ceased  later  than  the  fifty-fifth  year  of  life,  there  were  2  only  with 
less  than  2  children,  but  10  who  had  each  given  birth  to  from  6  to  8 
children.  A  similar  influence  is  exercised  by  the  function  of 
lactation.  Among  40  women  who  had  not  suckled  their  children, 
the  average  duration  of  menstrual  activity  was  4  years  less  than  the 
general  mean. 

As  regards  the  conditions  of  life,  L.  Mayer  affirms  that  the  dura- 
tion of  sexual  activity  among  well-to-do  women  is  on  the  average 
a  year  and  a  half  longer  than  among  women  of  the  working  classes. 

Metschnikoff  has  drawn  attention  to  the  remarkable  disharmony 
in  the  development  of  three  of  the  phases  of  the  sexual  life  of 


INTRODUCTION. 


33 


woman,  inasmuch  as  the  sexual  impulse,  the  union  of  the  sexes, 
and  the  capacity  for  procreation,  which,  considering  their  nature 
and  purpose,  might  have  been  expected  to  be  attuned  so  as  to  act 
in  harmony,  exhibit  as  a  matter  of  fact  no  such  relation;  the  dif- 
ferent factors  of  the  sexual  function  develop  independently  and 
unharmoniously.  In  a  child  not  yet  fitted  to  fulfil  the  function  of 
procreation,  the  sexual  impulse  will  none  the  less  make  its  appear- 
ance, and  be  liable  to  misuse.  In  the  girl  the  pelvis  does  not  attain 
that  complete  development  which  fits  it  for  the  process  of  parturi- 
tion until  toward  the  age  of  twenty,  whilst  puberty  occurs  at  the  age 
of  sixteen.  "A  girl  of  ten  is  capable  of  aspiring  to  play  the  part  of 
a  woman,  but  not  before  the  age  of  sixteen  is  she  fitted  to  play  that 
part,  nor  indeed  fitted  to  become  a  mother  before  the  age  of  twenty." 

In  general,  we  may  say,  regarding  the  women  of  our  own  part 
of  the  world,  that  in  those  who  are  healthy,  who  lead  a  regular 
life,  are  well  fed,  free  from  the  pressure  of  anxieties,  with  their 
sexual  functions  sufficiently  exercised,  the  duration  of  the  sexual 
life  is  longer  than  in  women  whose  circumstances  are  the  reverse 
of  those  just  enumerated.  It  is  a  sign  of  decadence  when  women  of 
the  well-to-do  classes,  leading  a  life  of  ease,  manifest  a  diminished 
duration  of  the  sexual  life.  The  greatest  physical  power  and  the 
highest  ethical  development  are  associated  with  a  lengthening  of 
life  in  general,  and  associated  also  with  a  lengthening  alike  in  the 
sexual  life  of  woman  and  the  sexual  potency  of  man.  A  decline  in 
morals  and  culture  entails  a  diminution  of  sexual  vital  capacity, 
this  being  true  alike  of  individuals,  of  families,  and  of  nations. 
Woman  is  venerated  and  valued  the  more,  the  longer  the  duration 
of  her  sexual  life ;  a  woman  in  whom  the  sexual  life  is  short  quickly 
loses  value  and  significance,  both  in  domestic  and  in  social  circles. 

The  social  significance  of  the  sexual  life  of  woman  is  dispropor- 
tionately greater  and  farther  reaching  than  the  sexuality  of  the  male, 
as  the  former  is  concerned  with  the  fundamental  principles  of  human 
social  life,  influencing  the  constitution  of  the  family,  and  controlling 
the  good  of  the  coming  race.  Sexual  purity,  which  to  the  youth  is  a 
romantic  dream,  is  to  the  maiden  a  vital  condition  of  existence ;  adul- 
tery, in  the  husband  a  pardonable  transgression,  is  in  the  wife  an 
overwhelming  sin  committed  against  family  life.  To  the  freedom 
of  the  male  in  affairs  of  love  is  opposed  the  strict  restraint  of  the 
female,  based  on  monogamic  marriage.  The  sexual  needs  and 
desires  of  the  female  are  transformed  in  an  ideal  manner  by  means 
of  the  feeling  of  duty  of  the  wife  and  mother;  the  violent  pressure 
of  the  sexual  impulse  is  restrained  by  the  opposition  of  ethical 
forces.  When  this  restraint  fails,  the  running  off  the  rails  that  en- 
sues has  a  far  profounder  influence  in  the  case  of  the  female  than 


34  THE  SEXUAL  LIFE  OF  WOMAN. 

of  the  male,  an  influence  not  limited  to  her  own  personality,  but 
dragging  down  the  whole  family  into  the  abyss  of  consequences, 
into  the  depths  of  moral  and  physical  destruction. 

Though  in  nature  everywhere  the  same,  the  sexual  life  of  woman 
exhibits  in  the  various  gradations  of  social  life  different  outward 
manifestations,  from  the  brutal  sexual  congress  that  does  not  greatly 
shun  publicity;  to  the  modern  would-be  philosophical  free  love.  And 
throughout  all  variations  the  two  darkest  points  remain,  the  illegiti- 
mate child  and  venereal  infection,  both  of  which  entail  upon  the 
woman  the  most  unspeakable  anxieties  and  the  greatest  possible 
misery,  whilst  the  man  who  is  in  either  case  to  blame  passes  com- 
paratively unscathed. 

The  social  sexual  position  of  woman  suffers  most  at  the  present 
day  from  the  mature  age  at  which  under  existing  social  conditions 
men  are  alone  able  to  marry  and  from  the  ever-increasing  number  of 
cases  of  venereal  infection.  In  both  these  directions  social  science 
and  medical  skill  must  work  hand  in  hand  for  the  amelioration  of 
the  sexual  life  of  woman. 

On  the  twentieth  century  falls  the  duty  of  furnishing  a  solution 
for  these  problems.  Contesting  voices  are  heard  on  all  sides.  Tol- 
stoi's rigid  demand  for  complete  sexual  abstinence,  the  exhortation 
of  the  professors  of  the  German  universities  to  their  students  in 
favor  of  moral  purity,  the  associations  for  the  official  prevention 
of  venereal  diseases,  the  agitation  among  young  men  in  favor  of 
abstinence  from  sexual  intercourse  before  marriage,  finally,  the 
clamorous  voices  of  the  supporters  of  women's  rights  —  all  these 
are  influences  within  the  sphere  of  sexual  morality  which  must  lead 
slowly  but  surely  to  extensive  social  changes  in  the  sexual  life  of 
women. 

The  discussion  of  the  sexual  life  of  woman,  which  for  many 
centuries  was  concealed  by  a  thick  veil  from  the  eyes  of  the  profane; 
or  was  viewed  only  through  the  frosted  glass  of  poetical  metaphor, 
has  in  recent  times  assumed  a  quite  revolting  character.  Not  only 
have  the  acquired  liberties  and  the  social  aims  of  the  present  day 
a  tendency  to  give  to  women  in  general  a  freer  and  higher  position, 
to  emancipate  them  from  the  bgnds  in  which  owing  to  the  conditions 
of  family  life  they  have  so  long  been  shackled,  but  some  members 
of  the  women's  rights  party  go  even  farther,  and  demand  for 
women  greater  freedom  in  the  sphere  of  sexual  activity. 

With  this  end  in  view  the  sexual  life  of  woman  is  used  as  the  ful- 
crum of  the  lever,  and  is  withdrawn  from  the  twilight  into  the 
open  light  of  day,  or  indeed  too  often  into  a  dazzling  and  altogether 
false  illumination.  Women  writers  especially,  who  have  hitherto 
been  accustomed  to  delude  themselves  and  the  world  with  sen- 


INTRODUCTION.  35 

sational  representations  of  the  feminine  soul,  of  feminine  modesty, 
and  the  fineness  of  feminine  sensibility  in  matters  sexual,  now  find 
their  greatest  joy  in  unveiling  themselves  and  their  sisters  before 
the  face  of  all  the  world,  and  in  discussing  in  the  plainest  language 
the  most  intimate  processes  of  the  genital  organs.  In  writings 
exhibiting  but  little  good  taste,  though  all  the  more  temperament, 
they  emphasize  again  and  again  one  side  only  of  the  sexual  life, 
to-wit,  the  sexual  impulse,  the  force  of  which  is  intentionally  ex- 
aggerated to  a  high  degree,  so  that  it  is  described  as  a  mighty  cur- 
rent of  passion,  which  may  with  great  pains  be  held  in  check  for  a 
season,  but  must  ultimately  break  loose,  and  with  devastating  rage 
must  overwhelm  everything  which  has  hitherto  been  regarded  as 
discipline  and  good  morals.  Young  girls,  even,  step  down  into  the 
arena  to  take  part  in  the  contest  concerning  the  reform  that  is 
to  take  place  in  the  relations  between  men  and  women.  Especially 
sensational  in  this  connection  was  Eine  filr  Viele.  Aus  dem  Tage- 
buche  eines  Mddchens  von  Vera,™  a  book  which,  totally  ignoring 
the  biological  differentiation  of  the  sexes  and  their  diverse  sociologi- 
cal course  of  development,  goes  so  far  as  to  insist  that  from  the 
man  entering  upon  marriage,  as  from  the  woman,  sexual  purity 
and  virginity  are  to  be  demanded.  (The  heroine  of  the  book  com- 
mits suicide  because  her  lover  has  in  earlier  years  had  experience  of 
sexual  intercourse.) 

From  a  mistaken  standpoint  other  supporters  of  women's  rights 
oppose  the  ideal  method  in  sex-relations,  life-long  monogamy,  and 
the  ideal  of  sexual  sensibility,  motherhood,  and  they  put  forward 
quite  new  sexual  pretensions  on  behalf  of  women,  as  belonging  to 
them  by  natural  right.  Upon  these  pretensions  it  is  the  duty  of 
physicians,  who  truly  know  and  truly  prize  womanhood,  to  pass  their 
judgment,  and  that  judgment,  which  will  find  ample  justification 
in  the  ensuing  descriptions  of  the  individual  phases  of  the  sexual  life 
of  woman,  is  that  the  modern  movement  on  behalf  of  the  emancipa- 
tion of  women  goes  much  too  far.  We  do  not,  however,  mean  to 
imply  that  this  movement  is  totally  unjustified. 

The  growing  girl  must  not,  as  has  hitherto  been  the  case,  be  kept 
in  a  state  of  ignorance  (which  is  indeed  in  most  cases  apparent 
merely)  regarding  the  sexual  processes  of  her  own  body,  she  must 
no  longer,  when  she  asks  to  be  informed  concerning  these  matters, 
be  put  off  with  conventional  lies  and  prevarication.  But  her  en- 
lightenment must  not  be  effected  in  such  a  manner  as  to  lead  to 
excitement  and  excessive  stimulation,  to  the  awakening  of  slumber- 
ing feelings,  and  to  the  conversion  of  fantasy  into  a  devouring 
flame.  Sexual  enlightenment  must  not  be  made  an  excuse  for  the 

18  "  One  for  Many.    Leaves  from  the  Diary  of  a  Maiden  of  Vera." 


36  THE  SEXUAL  LIFE  OF  WOMAN. 

unchaining  of  sensibility.  When  about  to  be  married,  a  woman 
should  certainly  be  instructed  regarding  her  sexual  duties  and 
rights,  and  enter  as  one  well  informed  into  the  act  in  which  she  is 
to  play  a  leading  part.  But  she  ought  not,  with  the  excessive 
valuation  of  herself  attained  in  recent  times,  to  regard  the  man 
as  her  enemy,  as  one  whom  she  is  always  justified  in  fighting  and 
always  ready  to  fight  with  the  equal  weapons  of  sexual  transgres- 
sion. It  cannot  be  doubted  that  the  ideal  of  "  pure  marriage  "  at 
an  early  age  is  one  greatly  to  be  prized  as  the  foundation  of  a 
powerful  future  generation ;  but  the  real  nature  of  the  male  must 
not  be  overlooked,  nor  must  his  sexual  honor  be  put  to  too  difficult 
a  test.  We  regard  as  reasonable  the  modern  demand  of  woman 
that  in  marriage  her  individuality  should  not  be  buried,  and  that 
space  should  be  given  for  the  development  of  her  personality;  but 
every  sober-minded  person  will  reject  the  "  moral  demand "  for 
"  ideal  passion  "  in  accordance  with  "  entire  mutual  freedom "  in 
the  sexual  relation  between  man  and  wife,  and  will  regard  such 
free  love  as  social  insanity  and  as  a  barbaric  retrogression  toward 
the  rude  sexual  habits  of  savage  peoples.  Further,  in  view  of  the 
continually  increasing  intensity  of  the  struggle  for  existence  and  in 
view  of  the  difficulties  of  the  task  of  rearing  children,  we  cannot 
fail  to  recognize  that  it  is  not  right  for  women  to  be  overburdened 
with  the  task  of  reproduction,  and  that  she  does  not  live  simply 
and  solely  for  the  bearing  of  children  —  but  those  rush  to  the  other 
extreme  who  undervalue  motherhood  and  the  duties  of  maternity, 
who  speak  scornfully  of  the  woman  who  is  "  a  mother,  and  a 
mother  only,"  who  despise  women  whom  they  regard  merely  as 
"  means  for  the  production  of  children,"  and  who  employ  all  possible 
methods  to  free  women  from  the  pressing  claims  of  nature  and 
of  society. 

In  all  social  circumstances  and  in  all  times  the  great  principle  of 
sexual  morality  must  dominate  the  sexual  life  of  woman.  As  the 
ethical  characteristics  of  the  three  great  epochs  in  that  sexual  life 
we  recognize  the  purity  of  the  maiden,  the  faithfulness  of  the  wife, 
and  the  love  of  the  mother.  But  within  the  limits  imposed  by  these 
demands  it  is  still  possible  to  satisfy  the  modern  claim  for  a  free 
development  of  the  personality,  and  to  accommodate  the  circum- 
stances of  the  sexual  life  to  the  individual  vital  needs  and  vital 
claims  of  the  present  day. 


I.  THE  SEXUAL  EPOCH  OF  THE  MENARCHE. 


(PUBERTY.) 

The  term  menarche  (A"?'",  a  month,  dpx1!,  the  beginning)  was 
introduced  by  me  into  medical  literature  to  denote  the  period  of 
life  in  which,  as  a  sign  of  puberty,  menstruation  first  makes  its  ap- 
pearance. 

The  age  at  which  this  occurs  is  subject  to  variations  depending 
upon  race,  occupation,  hereditary  tendencies,  and  climate;  but  in 
Germany  and  Austria  the  average  age  at  puberty  is  14  or  15,  the 
extreme  limits  being  12  to  19. 

Until  about  the  age  of  13,  the  physical  differentiation  of  the 
sexes,  except  for  the  anatomical  peculiarities  of  the  genital  organs, 
is  in  our  climates  a  trifling  one.  But  at  puberty  the  important 
changes  occur  by  which  the  sexes  are  so  strikingly  differentiated. 
Whereas  in  the  growing  boy  all  physical  change  takes  the  form 
of  increasing  strength  and  energy,  in  the  "development  of  the  girl, 
we  note  the  appearances  of  the  rounded  outlines  so  characteristic 
of  womanhood.  At  the  same  time  the  voice  alters,  becoming  less 
sharp,  with  a  softer  quality,  and  yet  a  fuller  tone;  and  we  may 
observe  that  young  brunettes  have  commonly  a  contralto  voice, 
young  blondes,  more  often  a  soprano.  The  intellectual  changes  un- 
dergone by  the  girl  at  puberty  are  no  less  extensive  and  characteristic 
than  the  physical  changes.  In  brief,  the  undifferentiated,  neuter 
girl  is  transformed  into  a  young  woman,  endowed  with  all  the  at- 
tributes, mental  and  bodily,  characteristic  of  femininity. 

As  regards  the  age  at  which  the  menarche  usually  occurs,  and 
the  manner  in  which  its  occurrence  is  anticipated  or  retarded  by  the 
various  influences  already  mentioned,  the  following  propositions  may 
be  put  forward,  based  on  the  available  statistics  and  observations: 

i.  .Climate  is  an  important  factor.  In  the  torrid  zone,  menstrua* 
tion  appears  at  a  very  early  age,  on  the  average  from  II  to  14;  in 
the  temperate  zone,  it  appears  later,  on  the  average  from  the  age  of 
13  to  16;  in  the  frigid  zone,  later  still,  on  the  average  from  the  age 
of  15  to  18.  The  mean  temperature  of  the  atmosphere  appears  to 
have  a  direct  influence  on  the  age  at  which  menstruation  begins, 
the  hotter  the  climate,  the  earlier  being  the  menarche.  The  height 
of  the  place  of  residence  above  the  sea  level  and  its  distance  from 
the  coast  also  have  a  certain  influence. 

[37] 


38  THE  SEXUAL  LIFE  OF  WOMAN. 

2.  Race  and  constitution  have  a  distinct  influence  upon  the  age 
at  which  menstruation  makes  its  appearance.     In  women  of  the 
Semitic  races  the  menarche  occurs  earlier  than  in  women  of  the 
Aryan  races.     The  average  age  at  which  menstruation  begins  is 
in  Jewish  girls,  from  14  to  15;  in  Magyar  girls  from  15  to  16;  in 
German  girls  from  16  to  i6£ ;  and  in  Slavonic  girls  from  16  to  17. 

In  general  the  menarche  is  earlier  in  girls  of  a  sanguine,  lively 
temperament  and  a  powerful  constitution  than  in  girls  of  a  phlegma- 
tic temperament  and  a  weakly  constitution;  further,  other  things 
being  equal,  menstruation  appears  earlier  in  brunettes,  girls  with 
black  hair,  thick  skin,  dark  eyes,  and  a  dark  complexion,  than  it  ap- 
pears in  blondes,  girls  with  light  hair,  thin  skin,  blue  eyes,  and  a  fair 
complexion. 

3.  The  age  at  which  menstruation  begins  is  also  affected  by  the 
conditions   of   life   and   the    social   circumstances.      In   the   higher 
circles  of  society,  in  the  upper,  well-to-do  classes,  menstruation 
appears  earlier  than  among  women  of  the  laboring  classes,  who 
are  compelled  to  strive  for  their  daily -bread.     Amongst  upper- 
class  girls  the  menarche  occurs  at  the  age  of  14  in  one-fourth  of 
their  number,   whereas  among  lower-class  girls  barely   one-sixth 
begin  to  menstruate  at  the  age  of  14. 

In  large  towns,  again,  menstruation  appears  earlier  than  in  small 
towns,  whilst  in  the  open  country  the  menarche  is  still  further  de- 
layed. In  the  women  of  Paris  the  average  age  at  the  menarche  is 
14  years  and  6  months,  in  the  women  of  smaller  French  towns  it  is 
14  years  and  9  months,  in  French  countrywomen  it  is  14  years  and 
10  months. 

How  far  the  mode  of  nutrition  is  concerned  in  the  production  of 
these  results  is  not  yet  determined. 

4.  The  time  of  the  menarche  appears  to  be  influenced  by  inherit- 
ance to  this  extent,  that  the  daughters  of  women  who  began  to 
menstruate  early  begin  themselves  to  menstruate  at  an  early  age, 
whereas   in   other .  families   we  observe   that   both    mothers   and 
daughters  began  to  menstruate  late.     But  this  relation  is  by  no 
means  a  constant  one. 

PIoss  has  collected  observations  made  in  various  countries  and 
towns  regarding  the  age  at  which  menstruation  begins,  and  the 
mean  results  of  these  observations  are  given  below. 

The  average  age  at  which  menstruation  began  was: 

In  Swedish  Lapland 18  years,  o  months,  o  days. 

In  Christiania 16  years,  o  months,  25  days. 

In  Copenhagen 16  years,  9  months,  12  days. 

In  Munich 16  years,  5  months,  12  days. 

In  Gottingen 16  years,  2  months,  2  days. 

In  Vienna 15  years,  8  months,  15  days. 

In  Berlin ; : 15  years,  7  months,  6  days. 


39 


In  Stockholm 15  years, 

In  Manchester 15  years, 

In  Warsaw 15  years, 

In  London,  between 15  years, 

and 14  years, 

In  Paris,  between  15  years, 

and 14  years, 

In  Madeira 14  years, 

In  Montpellier * 14  years, 

In  Corfu : 14  years, 

In  Marseilles 

In  Calcutta 


In  Egypt 


6  months,  22  days. 

6  months,    o  days. 
I  month,    23  days. 

1  month,      4  days. 
9  months,    9  days. 

7  months,  18  days. 
5  months,  17  days. 
3  months,    o  days. 

2  months,    o  days. 
o  months,    o  days. 

13  years,  II  months,  II  days. 
12  years,    6  months,    o  days. 


10  years,    o  months,     o  days. 


The  collective  results  of  the  investigations  of  French  authors 
regarding  the  average  age  at  which  menstruation  first  appears  are 
given  in  the  following  table : 


I.     IN  TEMPERATE  CLIMATES  : 


Observer. 


Place. 


No.  of  Cases. 


De  Spye Paris 

Dubois Paris 

Raciborski Paris 

M.  Despines Paris 

Arau Paris 

Courty Montpellier 

Puech Nimes  .  .  . . 

M.  Despines Toulon  .  .  . 

M.  Despines Marseilles  .  , 

Puech Toulon  .  .  . 

Grey London  .  . 

Lee  &  Murphy  . .    . .  London  .  . 

Torisiano Corfu  .  .  .. 

Lebrun Warsaw  . 


1,000 

600 
200 

85 

IOO 

600 

941 

43 

25 

144 

i,498 

i,7i9 

33 

IOO 


Average  Age. 
15  years,    o  months. 
15  years,    3  months. 
14  years,     5  months. 

14  years,  II  months. 

15  years,    4  months. 

3  months. 
2  months. 
I  month. 
i  month. 
I  month. 
6  months. 
6  months. 
6  months, 
i  month. 


from  these  observations  we  obtain  an  average 

II.    IN  COLD  CLIMATES  : 
Observer.  Place.  No.  of  Cases. 

Ravn  Copenhagen 3,840 

Frugel Christiania 157 

Dubois Russia 600 

Faye    Norway 100 

Lundborg Esquimaux 16 

Wistrand   Stockholm  .  IOO 


14  years, 

*  14  years, 

14  years, 

14  years, 

14  years, 

15  years, 
15  years, 

14  years, 

15  years,     I 

of  15  years. 


Average  Age. 
16  years,  9  months. 
6  months. 
8  months. 
6  months. 
6  months. 


16  years, 
16  years, 
15  years, 
15  years, 
15  years, 


7  months. 


from  these  observations  we  obtain  an  average  of  16  years  and  3 

months. 


III.    IN  HOT  CLIMATES: 
Observer.  Place.  No.  of  Cases. 

Goodeve Calcutta 

Lith Deccan 

Roberton Calcutta 

Webb Calcutta 

Dubois Asia 

from  these  observations  we  obtain  an  average 
months. 


Average  Age. 

12  years,    5  months. 

13  years,    5  months. 
12  years,     6  months. 
12  years,     5  months. 
12  years,  n  months. 

of  12  years  and  7 


THE  SEXUAL  LIFE  OF  WOMAN. 


In  6,550  cases  collected  by  Krieger  menstruation  first  appeared 


At  the  age  of: 
9  years  in 

10  years  in 

11  years  in 

12  years  in 

13  years  in 


I  instance. 
7  instances. 
43  instances. 
184  instances. 
605  instances. 

14  years  in  1193  instances. 

15  years  in  1240  instances. 

16  years  in  1026  instances. 

17  years  in     758  instances. 

18  years  in     582  instances. 

19  years  in     425  instances. 


At  the  age  of: 

20  years  in  281  instances. 

21  years  in  in  instances. 

22  years  in  55  instances. 

23  years  in  15  instances. 

24  years  in  15  instances. 

25  years  in  I  instance. 

26  years  in  4  instances. 

27  years  in  2  instances. 

28  years  in  I  instance. 

29  years  in  i  instance. 


From  these  figures  it  appears  that  in  the  6,550  cases  under  con- 
sideration, the  age  15  was  that  at  which  the  first  appearance  of 
menstruation  was  most  frequently  observed,  namely  in  1,240 
instances,  or  18.9  per  cent.  The  age  14  comes  next,  with 
1,193  instances,  or  18.2  per  cent.  The  case  in  this  series  in  which 
menstruation  appeared  earliest,  namely  in  the  ninth  year,  was  ob- 
served by  Mayer,  the  girl  being  a  blonde  of  average  height,  good 
family,  and  German  descent;  the  case  in  which  menstruation 
appeared  latest,  namely  in  the  twenty-ninth  year,  was  that  of  a 
woman  living  in  Berlin,  who  was  sickly  and  chlorotic  up  to  the 
time  of  her  marriage,  and  in  whom  menstruation  did  not  appear 
until  some  years  after  that  event. 

As  regards  climatic  influences,  all  the  data  at  our  disposal  prove 
that  the  hotter  the  climate  the  earlier  the  menarche.  According 
to  Marc  d'Espine  the  age  at  puberty  varies  in  an  almost  geometri- 
cal ratio  with  the  mean  annual  temperature. 

The  dependence  of  the  menarche  upon  climatic  influences  is 
clearly  shown  by  the  statistical  data  collected  from  various  regions 
of  the  world.  We  append  the  general  compilation  of  Gcbhard 
dealing  with  this  question. 

A.   EUROPE. 

For  Europe  the  data  furnished  by  Floss  are  grouped  by  Geb- 
hard  in  the  following  manner. 


i.  Northern  Europe. 

The  average  age  at  which  menstruation  first  appears,  according 
to  the  older  statistics,  is  in  Swedish  Lapland  18,  in  Norway,  16.12. 
In  Copenhagen  it  is  16.75,  m  St.  Petersburg  14.5. 

More  recent  statistics  for  Finland  are  furnished  by  Engstrom. 


THE  SEXUAL  EPOCH  OF  THE  MENARCHE.  41 

Among  3,500  women  of  pure  Finnish  descent,  he  found  that  men- 
struation began  : 

At  the  age  of:  At  the  age  of: 

8  years  in      2  instances.  18  years  in  195  instances. 

9  years  in      2  instances.  19  years  in    91  instances. 

10  years  in  4  instances.  20  years  in  31  instances. 

11  years  in  41  instances.  21  years  in  8  instances. 

12  years  in  178  instances.  22  years  in  10  instances. 

13  years  in  458  instances.  23  years  in  2  instances. 

14  years  in  715  instances.  24  years  in  I  instance. 

15  years  in  7/8  instances.                    ,       25  years  in  o  instance. 

16  years  in  614  instances.  26  years  in  I  instance. 

17  years  in  369  instances. 

Thus,  in  nearly  half  of  all  Finnish  women,  menstruation  begins 
with  the  completion  of  the  fourteenth  and  fifteenth  years.  The 
statistics  include  women  of  all  classes  of  society. 

At  the  Pirogoff  Congress  Grusdeff  furnished  particulars  of  the 
first  onset  of  menstruation  in  Russia  among  10,000  women.  Men- 
struation began  : 

At  the  age  of:  At  the  age  of: 

9  years  in  i  instance.  18  years  in  910  instances. 

10  years  in  4  instances.  19  years  in  498  instances. 

11  years  in  31  instances.  20  years  in  183  instances. 

12  years  in  244  instances.  21  years  in  65  instances. 

13  years  in  864  instances.  22  years  in  19  instances. 

14  years  in  1641  instances.  23  years  in  5  instances. 

15  years  in  1795  instances.  24  years  in  3  instances. 

16  years  in  2012  instances.  32  years  in  I  instance. 

17  years  in  1692  instances. 

In  women  of  German  race  living  in  Russia  puberty  was  earliest, 
occurring  at  the  average  age  of  15.16  years;  in  Finnish  women 
it  was  latest,  occurring  at  the  average  age  of  16.17 


2.  Middle  Europe. 

In  Germany,  according  to  the  tables  of  Krieger  and  L.  Mayer, 
who  have  recorded  11,500  cases  in  all,  menstruation  begins  most 
commonly  (in  18.931  per  cent,  of  the  cases)  at  the  age  of  15;  the 
next  most  frequent  age  is  14  (18.213  per  cent,  of  the  cases). 

For  Berlin,  in  a  number  of  cases  collected  from  the  lower  classes 
of  society,  we  find  the  average  age  for  the  first  appearance  of  men- 
struation to  be  16.18  years. 

Notwithstanding  the  more  northerly  situation  of  Berlin,  the 
average  age  at  puberty  is  somewhat  less  than  in  Munich,  situated 
4^  degrees  to  the  southward,  for  the  reason  that  the  retardation  de- 
pendent upon  altitude  makes  itself  manifest  in  the  latter  town,  which 
is  situate  about  500  metres  (1,640  feet)  higher  above  the  sea  level. 
Whereas  in  Berlin  18  per  cent,  of  all  cases  begin  to  menstruate  at 
the  age  of  14,  and  19  per  cent,  at  the  age  of  15,  in  Munich  the  two 


42  THE  SEXUAL  LIFE  OF  WOMAN. 

leading  years  are  15  with  a  percentage  of  17^,  and  16  with  a  per- 
centage of  i8|. 

In  Great  Britain,  according  to  Krieger,  the  average  age  at  which 
menstruation  begins  is  15  years,  I  month,  and  5  days.  For  Man- 
chester the  age  given  is  1 5  years,  6  months,  and  23  days.  In  France, 
according  to  the  calculation  of  Brierre  de  Boismont,  the  most  fre- 
quent age  for  the  first  onset  of  menstruation  is  16.  In  Paris  the 
average  age  is  14  years,  6  months,  and  14  days.  Bohemia,  Upper 
and  Lower  Austria,  and  Moravia  have  an  average  age  of  16  years 
and  2  to  3  months. 

3.  Southern  Europe. 

In  Southern  Europe  the  influence  of  the  higher  mean  temperature 
manifests  itself.  The  average  age  at -which  Spanish  girls  begin 
to  menstruate  is  12.  In  Northern  and  Middle  Italy  the  most  fre- 
quent age  is  14;  in  Southern  Italy,  13.  In  Lyons  the  average  age 
at  which  menstruation  begins  is  14  years,  5  months,  and  29  days; 
in  Marseilles  and  Toulon  it  is  13  years  and  10  months.  For  Hun- 
gary, Doktor  gives  the  statistics  of  9,600  cases.  In  22*/j  per  cent, 
menstruation  began  at  the  age  of  15 ;  in  2oJ  per  cent,  at  the  age  of 
16,  and  in  10  per  cent,  at  the  age  of  17.  The  earliest  age  among 
these  cases  was  8  years;  the  latest,  33  years.  (The  latter  must  no 
doubt  be  regarded  as  pathological.) 

B.  ASIA. 

In  Palestine  puberty  most  commonly  occurs  at  the  age  of  13 ; 
in  Turkey  even  as  early  as  10.  Roinier  calculated  the  average  of 
742  cases  observed  in  Syria  to  be  the  age  of  12.  As  regards  Persian 
women,  the  data  vary  between  the  age  of  14  for  the  northern  part 
of  the  country  and  the  age  of  9  or  10  for  the  southern.  According 
to  Jonbert's  data  in  46.4  per  cent,  of  the  indigens  of  India,  menstrua- 
tion begins  at  the  age  of  12  or  13.  Similar  figures  are  given  for 
Ceylon  and  for  Siam.  In  Japan  menstruation  most  frequently  be- 
gins at  the  age  of  14,  sometimes  as  early  as  13;  mothers  of  15  are 
by  no  means  rarities  in  this  country,  but  for  menstruation  to  begin 
before  the  age  of  12  is  considered  a  very  exceptional  occurrence. 
According  to  a  table  dealing  with  584  women  of  Tokio  menstrua- 
tion began : 

At  the  age  of:  At  the  age  of: 

11  years  in  2  instances.  16  years  in  228  instances. 

12  years  in  2  instances.  17  years  in    68  instances. 

13  years  in  26  instances.  18  years  in     44  instances. 

14  years  in  78  instances.  19  years  in     10  instances. 

15  years  in  224  instances.  20  years  in      2  instances. 

The  data  available  regarding  China  are  so  exceedingly  variable 
that  little  importance  can  be  attached  to  them. 


THE  SEXUAL  EPOCH  OF  THE  MENARCHE.  43 

C.  AFRICA,  OCEANIA,  AND  AMERICA. 

The  average  age  at  which  menstruation  begins  in  the  negro 
women  of  Africa  is  from  10  to  13.  In  Algeria  puberty  occurs  at 
9  or  10  years.  Among  the  Australian  indigens,  menstruation  com- 
monly begins  as  early  as  8  years,  and  at  the  very  latest  at  the  age 
of  12  years.  The  data  available  concerning  the  indigens  of  the 
Oceanic  Archipelago  are  extremely  variable  and  inexact,  but  we 
cannot  go  far  astray  in  stating  the  age  of  puberty  among  these  to 
be  from  10  to  13.  In  tropical  South  America  girls  begin  to 
menstruate  from  the  age  of  9  to  14  years.  The  Indian  women  of 
North  America  begin  to  menstruate  at  the  ages  of  12,  13,  14,  or 
even  as  late  as  18  or  20.  In  the  Arctic  zone  of  North  America  and 
in  Greenland  the  onset  of  menstruation  is  delayed  till  17  and  even 
till  23  years. 

As  regards  the  position  in  life  and  the  upbringing  years  it  has  been 
shown  by  numerous  observers  that  among  the  well-to-do  classes, 
whose  mode  of  living  is  luxurious,  and  whose  social  circumstances 
allow  free  play  to  the  imagination,  menstruation  begins  at  an  earlier 
age  than  among  the  working  classes,  whose  life  is  one  of  want  and 
privation.  According  to  the  statistical  data  of  Mayer's  regarding 
6,000  women,  menstruation  began  : 

In  women  of  In  women  of 

the  upper  classes,     the  loiver  classes. 

At  the  age  of  13  years H-73  per  cent.          7.06  per  cent. 

At  the  age  of  14  years 23.90  per  cent.         13-33  per  cent. 

At  the  age  of  15  years 22.83  per  cent.         14.56  per  cent. 

At  the  age  of  16  years 14. 10  per  cent.         i6-53  per  cent. 

At  the  age  of  17  years 9.60  per  cent.        13-33  per  cent. 

From  this  table  we  learn  that  in  nearly  one-fourth  of  the  girls 
of  the  upper  classes  puberty  occurs  at  the  age  of  14,  whilst  in  girls 
of  the  lower  classes  barely  one-sixth  begin  to  menstruate  at  this 
age.  The  average  age  at  the  first  menstruation  in  girls  belonging  to 
the  upper  classes  is  seen  to  be  14.69  years,  but  in  girls  belonging 
to  the  lower  classes,  16.00  years.  According  to  other  observers  the 
average  age  at  the  first  menstruation  is : 

Brierre  de 

Boismont.  Tilt.  Krieger.  Ravn. 

(Paris.)         (London.)       (Berlin.)  (Copenhagen) 
Amongst  gentle  folk  and 

the  rich    , 13  y.    8m.       13  y.  5^2  m.       14  y.  I  m.       14  y.  3     m. 

Amongst    the    well-to-do 

middle  classes    14  y.    5  m.       14  y.  3^  tn.       15  y.  5  m.       15  y.  S1A  m. 

Amongst        the        lower 

classes 14  y.  10  m.  i6y.  8m.       i6y.5l/2m. 

Comparative  observations  on  women  living  in  towns  and  women 


44  THE  SEXUAL  LIFE  OF  WOMAN. 

living  in  the  country  show  also  that  in  the  former,  menstruation 
begins  on  the  average  at  an  earlier  age.  According  to  Brier  re  de 
Boismont,  the  average  age  at  the  first  menstruation  is: 

In  Paris 14  years,    6  months. 

In  small  towns   14  years,     9  months. 

In  country  districts 14  years,  10  months. 

Similarly  it  was  found  by  Ravn  that  menstruation  first  occurred: 

In  Copenhagen  at  the  average  age  of 15  years,  7  months. 

In  industrial  towns 15  years,  4  months. 

In  country  districts   16  years,  5  months. 

Mayer  states  that  the  average  age  at  which  the  first  menstruation 
occurs  is: 

In  townswomen 15 . 98  years. 

In  countrywomen   15 . 20  years. 

In  Italy,  according  to  Caldcrini,  in  a  thousand  instances,  menstrua- 
tion begins  at  the  age  of  14  in  280,  at  the  age  of  15  in  219,  at  the 
age  of  13  in  205,  at  the  age  of  12  in  116,  at  the  age  of  16  in  89,  at 
the  age  of  17  in  55,  at  the  age  of  18  in  14,  at  the  age  of  n  in  7,  at 
the  age  of  10  in  6,  and  at  the  age  of  20  in  6  instances.  In  girls  at- 
tending town  schools,  the  first  menstruation  most  commonly  oc- 
curs in  the  months  of  June  and  August ;  but  in  girls  attending 
country  schools  most  commonly  in  the  spring  months. 

A  certain  hereditary  predisposition  is  so  far  determinant  in  the 
matter  of  the  early  or  late  onset  of  the  first  menstruation,  that 
from  a  knowledge  of  the  age  at  which  menstruation  began  in  the 
mother,  we  are  able  with  great  probability  to  predict  the  age  at 
which  it  will  begin  in  the  daughter.  Among  fifty  cases  which  I  in- 
vestigated with  this  point  in  view,  I  found  forty-one  in  which  the 
daughters  of  mothers  who  had  begun  to  menstruate  early  began 
themselves  to  menstruate  early,  usually  indeed  in  about  the  same 
year  of  life;  or  conversely  that  when  the  mother  had  begun  to 
menstruate  late,  late  onset  of  menstruation  was  usually  to  be  ob- 
served in  the  daughter  also.  Tilt  relates  a  case  in  which  a  woman 
began  to  menstruate  at  the  age  of  fourteen,  and  her  daughter  and 
granddaughter  both  began  to  menstruate  at  the  same  age.  Court y 
observed  a  mother  who  began  to  menstruate  at  the  age  of  eleven, 
and  whose  eight  daughters  all  began  to  menstruate  at  the  same  age. 

Gynecologists  agree  in  stating  that  girls  of  sanguine  temperament 
and  powerful  constitution  begin  to  menstruate  earlier  than  weakly 
and  phlegmatic  individuals.  Tilt  describes  a  peculiar  ovarian  tem- 
perament, in  which  menstruation  begins  early ;  such  women  have 
as  a  rule  striking  nervous  sensibilities,  with  a  dark  complexion  and 
glistening,  longing  eyes,  always  surrounded  by  dark  rings. 


THE  SEXUAL  EPOCH  OF  THE  MENARCHE.  45 

The  opinion  is  general  that  in  girls  with  black  hair,  dark  eyes, 
thick  skin,  and  dark  complexion,  menstruation  begins  earlier  than 
in  blondes  with  blue  eyes  and  delicate  white  skin.  Brierre  de  Bois- 
mont  states  in  this  connection  that  not  fair  hair  only,  but  also  chest- 
nut-tinted locks,  indicate  a  late  onset  of  menstruation.  L.  Mayer 
found  that : 

Of  blondes.  Of  brunettes. 

17.20  per  cent.  18.84  per  cent,  began  to  menstruate  at  the  age  of...  14 
16.89  per  cent.  18.02  per  cent,  began  to  menstruate  at  the  age  of...  15 
15.14  per  cent.  16.59  per  cent,  began  to  menstruate  at  the  age  of...  16 

According  to  the  same  author,  the  average  age  at  which  men- 
struation begins  is : 

In  blondes  15-55  years. 

In  brunettes   15.26  years. 

As  regards  race,  it  is  well  known  that  in  Jewesses  menstruation 
begins  at  an  early  age.  According  to  Joachim  the  age  of  puberty 
varies  very  greatly  among  the  different  races  inhabiting  Hungary. 
The  first  menstruation  appears : 

In  Slavonic  girls  between  the  ages  of 16  and  17 

In  Magyar 15  and  16 

In  Jewish 14  and  15 

In  Styrian 13  and  14 

FIRST  APPEARANCE  OF  MENSTRUATION. 

The  first  appearance  of  menstruation  is  commonly  preceded  by 
various  symptoms  dependent  on  the  increased  flow  of  blood  to  the 
genital  organs.  Such  symptoms  are :  Sacrache ;  dragging  sensa- 
tion in  the  loins ;  an  indefinite  feeling  of  pressure  in  the  lower  part 
of  the  belly,  especially  in  the  region  of  the  uterus  and  the  ovaries, 
which  region  is  sometimes  also  tender  on  pressure ;  a  slight  feeling 
of  weariness  in  the  lower  extremities ;  sudden  flushings  or  pallors ; 
alternating  sensations  of  heat  and  chilliness,  sometimes  accompanied 
by  actual  though  slight  change  of  temperature.  In  many  cases  also 
there  are  disturbances  in  the  intestinal  evacuations  and  urinary  se- 
cretion, in  the  process  of  cutaneous  transpiration,  and  in  the  func- 
tional activity  of  the  gastro-intestinal  canal.  A  frequently  observed 
symptom  is  an  increased  irritability  of  the  entire  nervous  system, 
with  an  inclination  to  melancholy  and  indefinite  amorous  desires 
—  symptoms  which  Tilt  denotes  by  the  term  "  ovarianismus,"  Em- 
met by  the  term  "  erection,"  Lecal  by  the  term  "  phlogose 
amoureuse,"  and  the  older  writers  by  the  term  "  molimina  men- 
strualia." 

The  nervous  irritability  manifests  itself  already  before  the  ap- 
pearance of  the  menstrual  flow  by  headache  and  moodiness,  weari- 


46  THE  SEXUAL  LIFE  OF  WOMAN. 

ness,  nervous  irritability,  and  low  spirits ;  further,  by  slight  changes 
in  the  facial  aspect,  dark  rings  round  the  eyes,  spontaneous  blushing, 
uneasy  sensations,  epigastric  pain,  loss  of  appetite,  a  sensation  of 
pressure  in  the  abdomen,  palpitation,  vertigo,  dragging  sensa- 
tions passing  from  the  loins  to  the  thighs,  feeling  of  weakness  and 
numbness  in  the  lower  extremities  —  symptoms  which  often  endure 
for  several  months  and  in  such  cases  tend  to  lower  the  resisting 
powers  of  the  organism. 

Courty  enumerates  as  prodromal  symptoms  which  are  observed 
in  the  majority  of  girls  before  the  first  appearance  of  menstruation: 
swelling  and  tenderness  of  the  breasts,  sensation  of  fulness  and 
weight  in  the  hypogastric  region,  moderate  intestinal  meteorism, 
sacrache,  aqueo-mucous  vaginal  discharge,  finally,  an  itching  sen- 
sation in  the  genital  organs.  These  manifestations  may  also  as- 
sume a  morbid  character,  taking  the  form  of  violent  abdominal  and 
lumbosacral  pain,  general  fatigue  and  weakness,  dyspepsia  and 
diarrhoea,  cephalalgia,  various  kinds  of  neuralgia,  some  degree  of 
moral  aberration.  After  the  first  menstruation,  two  or  three  months 
may  elapse  before  the  girl  menstruates  again,  but  after  the  lapse  of 
a  year  the  flow  usually  recurs  at  quite  regular  periods.  Sometimes 
the  early  periods  are  very  violent  and  recur  very  frequently,  every 
twenty  days,  for  instance. 

The  greatest  increase  in  size  and  weight  occurs  in  the  female 
sex  at  the  time  of  the  menarche.  Amongst  the  poorer  classes  the 
greatest  development  in  size  and  strength  occurs  between  the  ages 
of  13  and  15  years,  whereas  in  the  upper  classes  of  society,  those 
who  ultimately  attain  the  same  weight  exhibit  their  greatest  growth 
at  the  ages  of  12,  13,  and  14  years.  According  to  Pagliani  the 
greatest  growth  in  the  female  sex  always  precedes  puberty,  so  that 
for  example  a  girl  who  begins  to  menstruate  at  the  age  of  12  will 
grow  most  rapidly  in  the  year  preceding  this,  whereas  a  girl  who  be- 
gins to  menstruate  at  a  more  advanced  age  will  not  undergo  her  most 
rapid  phase  of  growth  so  early  as  the  age  of  n.  According  to 
the  observations  of  Bowditch,  A.  Hey,  Lombroso,  Pagliani,  and 
Ploss,  up  to  the  age  of  n  or  12  years  the  growth  of  girls  exceeds 
that  of  boys,  but  whereas  in  girls  growth  ceases  suddenly  at  the  age 
of  14,  in  boys  growth  proceeds  regularly  up  to  the  age  of  16  years. 
At  birth  boys  are  on  the  average  I  cm.  (£")  longer  than  girls; 
but  during  puberty  the  female  sex  catches  up  the  male  in  height, 
or  even  surpasses  it.  According  to  Ploss,  a  girl  of  1 6  or  17  years 
is  as  tall  as  a  young  man  of  18  or  19  years. 

The  earlier  development  of  the  female  as  compared  with  the 
male  at  the  time  of  puberty  is  a  constant  phenomenon,  to  be  ob- 
served in  all  races,  in  every  climate,  and  in  all  strata  of  society. 


THE  SEXUAL  EPOCH  OF  THE  MENARCHE.  47 

According   to   the   statistical   data  published  by   the   authors   just 
quoted,  the  age  of  greatest  development  in  the  respective  sexes  is: 

In  the  female.         In  the  male. 

As  regards  weight  at  the  age  of 12  to  14  years.  14  to  17  years. 

As  regards  height  at  the  age  of 12  to  13  years.  12  to  15  years. 

As  regards  respiratory  capacity  at  the  age  of.     12  to  15  years.  15  to  17  years. 

As  regards  muscular  strength  at  the  age  of..     12  to  14  years.  14  to  15  years. 

Puberty  occurs  in  the  female  on  the  average  about  two  years 
earlier  than  in  the  male,  and  upon  this  difference  the  observed  dif- 
ferences in  growth  also  depend. 

The  menarche  in  the  wider  signification  of  the  term  includes  the 
development  which  occurs  at  the  time  of  puberty,  and  continues 
through  a  period  of  several  months,  and  even  years,  before  complete 
sexual  maturity  is  attained ;  and  includes  also  the  time,  which  may 
be  considerable,  following  the  first  appearance  of  the  menses  and 
before  the  regular  rhythm  of  the  menstrual  function  is  established 
and  the  full  development  of  the  female  genital  organs  is  at- 
tained. This  time,  which  forms  a  notable  phase  of  the  sexual  life 
of  woman,  is  characterized  by  great  changes  in  the  genital  organs 
and  in  the  vital  processes  connected  therewith,  by  a  strong  tendency 
to  suffer  from  a  series  of  very  various  pathological  changes  and 
disorders  of  function  in  the  principal  organs,  and  a  lessened  general 
resisting  power  to  disease  —  a  change  which  finds  its  most  definite 
expression  in  the  well-established  fact  that  in  this  period  of  life 
the  mortality  among  females  is  much  greater  than  among  males  of 
corresponding  age.  According  to  the  statistical  data  of  Quetclet 
and  Smits,  from  the  age  of  14  to  the  age  of  18  (the  period  of  the 
menarche)  there  are  128  deaths  of  females  for  every  100  deaths  of 
males;  and  even  in  the  four  succeeding  years,  from  the  age  of  18 
to  the  age  of  22,  the  unfavorable  conditions  peculiar  to  sex  are 
witnessed  by  105  deaths  of  females  to  every  100  deaths  of  males. 

Many  authors  draw  a  distinction  between  the  age  of  puberty 
(from  the  Latin  pubes,  puberis),  when  the  growth  of  the  pubic  hair 
occurs  as  an  external  sign  of  sexual  development,  and  the  age  of 
nubility  (from  the  Latin  nubere),  when  the  individual  becomes 
fitted  for  marriage.  The  distinction  is  a  partial  one  only,  inasmuch 
as  capacity  for  copulation  is  attained  already  at  puberty.  The  law, 
however,  maintains  such  a  distinction,  the  Austrian  Penal  Code, 
for  example,  regarding  intercourse  with  a  female  less  than  four- 
teen years  old  as  rape,  and  the  German  Code  likewise  punishing 
carnal  knowledge  of  a  girl  under  fourteen. 

The  signs  of  puberty  in  girls  were  noticed  and  explained  in  very 
early  times.  From  the  anthropological  studies  of  PIoss  and  Bartels 
we  take  the  following  data  regarding  this  matter.  In  the  Bible  we 
read  (Ezekiel,  xvi,  7)  :  "  Thy  breasts  are  fashioned  and  thine  hair 


48  THE  SEXUAL  LIFE  OF  WOMAN. 

is  grown,  whereas  thou  wast  naked  and  bare."  The  early  Indian 
physician,  Susruta,  refers  only  to  the  regular  recurrence  of  men- 
struation as  a  sign  of  puberty.  That  a  woman  is  menstruating  may 
be  known  by  the  fact  that  her  face  is  swollen  and  bright.  In  the 
Roman  Empire  Justinian  ordained  that  all  young  women  should  be 
examined  as  to  the  growth  or  absence  of  the  pubic  hair  in  order  to 
ascertain  if  they  were  ripe  for  marriage.  The  early  Chinese  phy- 
sicians recorded  that  in  every  woman  at  the  age  of  fourteen  or  fif- 
teen years  a  monthly  flow  of  blood  from  the  genital  organs  began, 
the  period  of  recurrence  being  thirty  days.  The  physicians  of  the 
Talmud  express  themselves  variously  regarding  puberty  in  women. 
In  one  place  they  advance  as  a  sign  of  puberty  the  growth  of  the 
hair  on  the  genital  organs ;  in  another  they  speak  of  the  notable  en- 
largement of  the  breasts,  and  mention  as  a  sign  of  more  complete 
sexual  development  that  the  nipples  become  elastic.  Other  Tal- 
mudists  refer  to  the  appearance  of  a  dark  brown  coloration  in  the 
areola  and  to  the  enlargement  of  the  mons  Veneris  as  signs  of 
puberty.  Savage  races  regard  the  first  appearance  of  the  men- 
strual flow  as  the  only  certain  sign  of  puberty,  and  among  many  such 
races  this  is  the  occasion  of  peculiar  ceremonial  rites.  The  attain- 
ment of  puberty  in  savage  tribes  is  often  solemnized  by  the  seclusion 
of  the  girls  from  the  time  of  the  first  menstruation ;  they  fast  during 
the  period  of  seclusion,  which  sometimes  terminates  in  an  elaborate 
ritual  of  purification. 

For  two  reasons  in  particular,  the  period  of  the  menarche  is  a 
time  of  storm  and  stress  to  women,  first  on  account  of  the  de- 
velopmental processes  in  the  genital  organs,  and  secondly  on  account 
of  the  intellectual  changes  that  occur  at  this  period. 

The  local  cause  is  to  be  found  in  the  extensive  transformation  of 
the  ovaries  and  the  uterus,  by  means  of  which  a  peculiar  and  power- 
ful stimulus,  the  menstrual  stimulus,  is  elaborated,  which  has  a  re- 
flex influence  upon  heart  and  brain,  vascular  and  nervous  systems, 
and  secretory  and  nutritive  processes.  Since  we  know  that  in  every 
premenstrual  period  by  the  growth  of  the  follicles  hyperaemia  is 
excited  in  the  ovary,  by  means  of  which  the  liquor  folliculi  is  in- 
creased in  amount,  we  can  well  understand  that  at  the  time  of  the 
menarche  the  ripening  of  the  graafian  follicles  is  accompanied  by  a 
considerable  degree  of  hyperaemia  of  the  ovaries  and  of  the  whole  of 
the  genital  organs,  now  undergoing  their  fullest  development,  and 
we  can  easily  see  how  this  hyperaemia  may  result  in  manifold  reflex 
disturbances.  But  in  addition  to  these  reflex  disturbances,  we  have 
once  more  to  take  into  consideration  the  as  yet  imperfectly  known 
chemical  processes  which  are  associated  with  the  ripening  and  de- 
velopment of  the  graafian  follicles,  and  an  abnormal  course  of 


THE  SEXUAL  EPOCH  OF  THE  MENARCHE.  49 

which  may  give  rise  to  a  disordered  constitution  of  the  blood,  mani- 
festing itself  as  chlorosis  or  in  other  ways.  In  connection  with  the 
growth  and  ripening  of  the  ova,  extensive  and  novel  demands  are 
made  on  the  organism,  and  these  may  well  endanger  metabolic 
processes  which  are  not  established  on  a  very  secure  foundation. 

The  other  cause  is  to  be  found  in  the  intellectual  processes  which 
occur  at  this  time  in  the  youthfully  receptive,  highly  sensitive 
organ  of  mind,  the  brain.  The  girl  growing  into  womanhood,  who 
with  astonishment  and  stress  has  witnessed  the  visible  changes  in 
her  body,  the  outward  signs  of  puberty,  as  they  gradually  make 
their  appearance,  receives  powerful  psychical  stimulation  which 
cannot  fail  to  exercise  an  influence  upon  the  entire  nervous  system 
and  its  complex  interlacements,  alike  in  the  sensory  and  in  the 
motor  sphere. 

The  degree  to  which  these  influences  radiating  from  the  genital 
organs  make  themselves  manifest  is  chiefly  dependent  upon  the 
resisting  power  of  the  nervous  system  as  a  whole,  upon  the  tem- 
perament, the  inherited  constitution,  and  the  mode  of  education  of 
the  young  girl.  In  children  belonging  to  families  noted  for  sensi- 
bility and  irritability,  in  dwellers  in  large  cities  who  have  attended 
high  schools  for  girls  and  have  at  an  early  age  lifted  the  veil  that 
covers  the  sexual  processes,  the  reflex  disturbances  of  the 
menarche  will  be  more  manifold  and  will  manifest  themselves  with 
greater  intensity  than  in  children  brought  up  in  country  districts, 
whose  sensibilities  are  chiefly  physical  and  whose  mind  is  less 
susceptible  to  the  influence  of  external  stimuli. 

A  further  important  consideration  is  the  time  at  which  the 
menarche  occurs,  and  whether  on  the  one  hand  it  is  at  or  near 
the  average  age,  or  whether  on  the  other,  as  precocious  menstrua- 
tion, it  is  unusually  early,  anticipating  the  general  bodily  develop- 
ment, or  again  as  retarded  menstruation  it  is  unduly  delayed.  In 
some  cases  of  retarded  menstruation,  the  e'xternal  genital  organs 
are  thoroughly  well  developed,  and  it  is  menstruation  only  that 
remains  in  abeyance ;  but  in  other  cases  the  external  genitals  are 
also  backward  in  development,  the  pubes  and  mons  Veneris  being 
but  sparsely  supplied  with  hair,  and  the  breasts  remaining  very 
small. 

In  addition  to  these  abnormal  temporal  relations  of  the  men- 
arche, certain  other  irregularities  at  the  commencement  of  men- 
struation are  worthy  of  note.  Thus,  the  first  menstruation  may 
be  normal,  but  thereafter  amenorrhoea  may  persist  for  several 
months,  or  if  the  flow  occurs  it  may  be  exceedingly  scanty,  or  very 
pale  in  color;  on  the  other  hand,  menstruation  may  be  very  profuse, 
lasting  many  days. 


5O  THE  SEXUAL  LIFE  OF  WOMAN. 

The  environment  in  which  the  young  girl  is  placed  during  the 
period  of  her  sexual  development  has  a  great  influence  on  the  proc- 
esses of  the  sexual  life  and  on  the  pathological  disturbances  that 
affect  these  processes. 

In  working-class  families  the  immoderate  physical  strain  often 
thrown  upon  girls,  in  many  cases  continuous  movements  of  the 
upper  extremities  whilst  the  lower  extremities  and  the  pelvis  are 
absolutely  quiescent,  or  conversely,  an  excessive  employment  of 
the  muscles  of  the  lower  extremities  —  these  circumstances  in  con- 
junction with  insufficient  nutriment,  night-work,  association  when 
at  work  with  persons  of  the  opposite  sex,  and  the  frequent  prem- 
ature sexual  stimulation,  will  combine  to  have  a  most  deleterious 
effect. 

Amongst  country-folk,  indeed,  the  girl  has  the  enjoyment  of 
fresh  air,  and  as  a  rule  nutritive  food,  moreover,  there  are  not  so 
many  occasions  of  nervous  stimulation;  puberty  therefore  arrives 
more  slowly  and  gives  rise  to  less  disturbance ;  but  the  ignorance 
of  the  girls  very  frequently  leads  to  an  early  experience  of  coition, 
the  natural  and  unnatural  consequences  of  which  have  then  to  be 
taken  into  account. 

Amongst  the  better  classes  of  townspeople  such  hygienic  regula- 
tions and  educational  measures  are  in  common  employment  that 
young  girls  during  the  }  ears  of  development  usually  receive  reason- 
able care  and  attention  —  but  very  frequently,  intercourse  with 
older  girls,  association  with  young  men,  visits  to  theatres,  evening- 
parties,  and  balls,  and  the  perusal  of  stimulating  literature,  form 
unfavorable  features  of  urban  life  which  exercise  their  inevitable 
effects  in  the  sexual  sphere.  In  some  cases,  fortunately  suffi- 
ciently rare,  the  stimulation  of  the  sexual  impulse  and  the  longing 
for  its  satisfaction  are  so  intense,  that  a  kind  of  dcmi-vicrge  is 
brought  into  being,  a  young  woman  who  is  concerned  only  to 
preserve  the  physical  token  of  virginity,  but  whose  thoughts  and 
fancies  are  anything  but  maidenly.  It  is  to  be  feared  that  in  con- 
sequence of  the  excessive  freedom  in  education  and  the  emanci- 
pated independence  of  feminine  youth,  these  "  half-virgins  "  are 
increasing  both  in  number  and  in  intensity,  a  fact  which  cannot 
fail  to  increase  also  the  number  of  sexual  maladies  and  perversions. 


Anatomical  Changes  in  the  Female  Genital  Organs  in  the  Period 

of  the  Menarche. 

The  female  reproductive  organs,  which  in  childhood  were  in  a 
comparatively  quiescent  state,  now  become  powerfully  active,  as  is 
witnessed  by  the  changes  that  occur  in  the  external  genitals. 


THE  SEXUAL  EPOCH  OF  THE  MENARCHE.  51 

The  soft,  hairless  vulva  of  the  child  becomes  enlarged  at  the 
time  of  the  menarche  by  the  deposit  of  fat,  and  its  substance  be- 
comes tough  and  elastic.  Some  time  before  puberty,  fine,  pale 
hairs  make  their  appearance  here  and  there,  but  not  until  puberty 
does  the  hairy  covering  of  the  pubic  region  become  more  or  less 
thick.  The  growth  of  the  denser  pubic  hair  begins  with  the  ap- 
pearance of  hairs  along  the  middle  of  the  mons  Veneris  and  at  the 
margins  of  the  labia  majora.  Early  sexual  development  is  com- 
monly indicated  by  an  early  and  thick  growtn  of  the  pubic  hair. 
In  the  virgin  this  hair  is  smoother  and  less  curly  than  in  the  later 
course  of  the  sexual  life.  In  certain  tribes  of  negroes  it  is  the 
custom  for  the  young  unmarried  girls  to  shave  off  the  pubic  hair, 
which  is  not  allowed  to  grow  freely  until  after  marriage.  In  some 
of  the  tribes  of  South  Sea  Islanders  it  is  customary  at  puberty  to 
tattoo  the  external  genitals  and  the  surrounding  skin. 

Fallopian  tube ;  !  Body  of  the  uterus 

Ovary 


Neck  of  the  uterus 
Broad  ligament  of  the   uterus  -& 

Vaginal  portion  of  the  cervix  --J 
Vagina  (mucous  membrane)  — 


FIG.  8. — Internal  genital  organs  of  a  newborn,  powerfully  developed 
female  infant.  (From  Toldt:  Atlas  of  Human  Anatomy. — Rebman  Com- 
pany, New  York.) 


In  young  virgins  the  rima  urogenitalis  or  vulval  cleft  is  closed 
by  the  accurate  opposition  of  the  labia  majora ;  the  labia  minora  or 
nymphae  are  delicate  in  texture,  rose-red  in  color,  hairless,  free 
from  fat,  and  completely  covered  by  the  labia  majora;  whilst  the 
clitoris  is  likewise  concealed.  The  sebaceous  glands  of  the  labia 
minora  secrete  a  smegma  which  collects  especially  around  the 
glans  clitoridis,  and  as  it  undergoes  decomposition  diffuses  a 
peculiar  odor,  resembling  that  of  old  cheese.  A  wing-like  elonga- 
tion of  the  labia  minora  in  young  girls,  with  free  secretion  and  a 
generally  moist  appearance,  leads  to  a  suspicion  of  the  practice  of 


.LE(£l£    C 


52  THE  SEXUAL  LIFE  OF  WOMAN. 

masturbation.     In  the  virgin  the  orifice  of  the  vagina  is  covered  by 
the  hymen. 


Suspensory  ligament  of  the  ovary*-*,. 

H* 
Ovary  PS^ 

Neck  of  the  uterus' 


/'Fallopian  tube 

Body  of  the  uterus 


itoneum 


"Urinary  bladder 


Vagina.  J» 


Rectum 


--  Urethra 


'"'Vestibule  of  the  vagina 
Hymen 


FIG.  9. —  Reproductive  organs  of  a  newborn,  powerfully  developed  female 
infant  in  median  sagittal  section.  (From  Toldt:  Atlas  of  Human  Anatomy. 
— Rebman  Company,  New  York.) 


The  entrance  to  the  vagina  in  the  virgin  is  rounded,  the  posterior 
border  of  the  aperture  being  deeply  concave,  whilst  the  anterior 
border  is  often  slightly  convex  backwards.  Where  this  feature  is 

Ovary.  Fallopian  tube 

Ligament  of  the  ovary    ] 


Vaginal  portion  of  the 
cervix 

Vagina     (posterior "^ 

wall ,  turned  out- 
wards) 

FIG.  io.—  Internal  genital  organs  of  a  girl  aged  eight  years.  Seen  from 
behind.  (From  Toldt:  Atlas  of  Human  Anatomy  — Rebman  Company, 
New  York.) 


10    VKAJiEU 

A  <1 0  3  T  fc  0   "1 0   3  FJ  3  J  J  0  0 

—:  r-'r:  i  r  r:      .r.      f^\r  r    (^,  r 


THE  SEXUAL  EPOCH  OF  THE  MENARCHE. 


53 


strongly  marked,  the  orifice  has  a  semi-lunar  shape.  The  posterior 
concave  border  projects  forward  in  the  form  of  a  fold,  continuous 
above  with  the  posterior  vaginal  wall ;  this  fold  is  the  hymen. 


Infundibulum  of  the  Fallopian  tube  .„ 


Ovary 
Body  of  the  uterus 


Suspensory  ligament 
of  the  ovary 


».  Fallopian  tube 
is.    Mesosalpynx 


Neck  of  the  uterus 
-  Utercsacral  ligament 
Ur'nary  bladder 


Perineum/ 


Glans  clitoridis 
vLabium  minus  or  nympha 
Labium  majus 
External  orifice  of  the  urethra 


Hymen 


FIG.  ii.. — Reproductive  organs  oi  a  girl  aged  ten  years  in  median  sagittal 
section.  Left  half.  (From  Toldt:  Atlas  of  Human  Anatomy. — Rebman 
Company,  New  York.) 


The  infantile  uterus  is  so  proportioned  that  its  neck  (colluin  vel 
cervix  uteri')  constitutes  the  larger  part  of  the  organ,  as  much 
indeed  as  two-thirds.  Owing  to  the  small  size  of  the  body  (corpus 
uteri),  the  whole  uterus  is  very  flat,  and  its  borders  ascend  in  a 
direction  almost  parallel  to  each  other,  diverging  somewhat 
abruptly  into  the  Fallopian  tubes,  recalling  in  some  degree  the  two- 
horned  embryonic  form  of  the  organ  (uterus  bicornis).  The  plicae 


54 


THE  SEXUAL  LIFE  OF  WOMAN. 


Prepuce  of  clitoris  \ 
Clans  clitoridis 

Fraenum  of  clitoris 
Labium  minus 

Hymen 
Urethral  ridge 


Posterior  vagina 
column 


Anterior  vagina 
column 


Transverse  rugae  of 
the  vagina 

Posterior  wall  of  the 
vagina 


Vaginal  fornix 


Supravaginal  portion  of  the 
cervix     . 


—  Mons  Veneris 


,T,abium  majus 


,  External  orifice  of  tue 
uretl:ra 


Orifice   of   Skene's 
tubule 


—  Orifice  cf  the  duct  of 
Bartholin's  gland 


Bartholin's  gland 


Mucous  membrane  of    the 

vagina 

Muscular  coat  of  the  vagina 
Anterior  wall  of  the  vagina 


--Anterior  lip  of  the  cervix 
Os  uteri  externum 
^-Posterior  lip  of  the  cervix 


.  FIG.  i2.— Female  external  genital  organs  of  a  virgin,  attached  to  the 
vagina  which  has  been  isolated  and  opened,  and  a  portion  of  the  cervix 
uteri,  Hymen,  etc.  (From  Toldt:  Atlas  of  Human  Anatomy. —  Rebman 
Company,  New  York.) 


THE  SEXUAL  EPOCH  OF  THE  MENARCHE. 


55 


PA--.-.       f.  c 


FIG.  i^. — The  external  genital  organs  of  a  virgin,  drawn  apart  transversely 
(after  von  Preuschen).  c.  Clitoris,  f.  c.  Fraenum  of  the  clitoris.  n.  Nymphae. 
1.  Labia  majora.  o.  u.  Urethral  orifice,  h.  Hymen,  f.  n.  Fossa  navicularis. 


THE  SEXUAL  LIFE  OF  WOMAN. 


palmatae  on  the  surface  of  the  cervical  canal,  which  make  up  the 
arbor  vitre  uterina,  are  strongly  developed;  the  median  longitudinal 
ridge  bifurcates,  and  its  divisions  can  be  traced  on  either  side 
into  the  uterine  orifice  of  the  Fallopian  tube  (ostium  uterinum 
tubrc}.  The  lips  of  the  vaginal  portion  of  the  cervix  are  com- 
paratively speaking  very  large  and  terminate  in  sharp  angles.  The 


FIG.  14. — Sagittal  section  of  the  female  pelvis  (after  Breiolei). 

vaginal  mucous  membrane  is  everywhere  beset  with  long  papillae. 
The  development  of  the  uterus  shortly  before  puberty  consists 
chiefly  in  the  enlargement  of  the  body  of  the  uterus,  and  the  growth 
of  its  walls  in  thickness. 

At  the  time  of  puberty,  according  to  Toldt,  the  body  of  the  uterus 
in  the  virgin  has  already  increased  till  its  length  is  half  that  of  the 
entire  organ;  and  at  the  first  appearance  of  menstruation  the  body 
and  neck  of  the  virgin  uterus  are  nearly  equal,  with  perhaps  a 
slight  preponderance  in  size  of  the  cervix,  and  the  walls  of  the 
uterus  have  become  convex.  In  consequence  of  this  change  the 
organ  becomes  pear-shaped,  and  the  uterine  cavity  (cavum  uteri} 
assumes  the  form  of  a  triangle  with  moderately  incurved  sides.  The 
cervical  canal  becomes  wider  in  the  middle ;  the  margin  of  the  os 
uteri  becomes  smooth  and  rounded.  The  walls  of  the  virgin  vagina 


THE  SEXUAL  EPOCH  OF  THE  MENARCHE.  57 

are  marked  with  numerous  dentate  transverse  ridges  (rug&), 
especially  near  the  lower  end  and  on  the  anterior  walls,  the  columns 
of  the  vagina  (columnce  ruga-rum),  from  which  the  transverse  ridges 
run  to  either  side  at  right  angles,  extend  half  way  up  the  vagina, 
and  are  of  a  hard  consistence. 

The  characteristic  changes  in  the  ovary  at  the  time  of  the  menarche 
originate  in  the  changes  undergone  by  the  ovarian  follicles.  A 
large  number  of  small  separate  follicles  is  to  be  found  already  in 
the  ovary  of  the  new-born  infant.  These  structures,  known  as  primi- 
tive follicles,  are  formed  by  detachment  from  the  egg-tubes  that 
grow  down  into  the  stroma  from  the  superficial  germinal  epithelium ; 
they  are  spheroidal  vesicles,  enveloped  by  a  single  layer  of  cubical 
cells,  and  their  interior  is  entirely  filled  by  the  primitive  ovum  or 
egg-cell.  This  latter  consists  of  very  finely  granulated  protoplasm 
with  spherical  nucleus  and  distinct  nucleolus,  but  no  trace  of  an 
investing  membrane  can  as  yet  be  discerned.  The  further  develop- 
ment of  the  ovarian  follicles  takes  according  to  Toldt  the  following 
course :  A  rapid  multiplication  of  the  cubical  cells  that  form  the 
wall  of  the  follicle  occurs,  so  that  the  ovum  is  surrounded  by  two, 
three,  or  several  layers  of  cubical  or  rounded  cells,  and  the  whole 
follicle  gradually  increases  in  size.  At  the  same  time  the  ovum 
assumes  an  eccentric  position  in  the  interior  of  the  follicle.  At  or 
near  the  middle  of  the  follicle  a  slit-shaped  space  now  appears, 
filled  with  a  clear  colorless  fluid.  As  this  space  gradually  enlarges, 
the  follicle19  becomes  converted  into  a  vesicle  filled  with  fluid,  the 
wall  of  which  is  composed  of  small  cubical  cells.  Simultaneously 
with  the  growth  of  the  follicle  a  lamination  of  the  elements  of  the 
surrounding  stroma  takes  place,  so  that  a  somewhat  sharply  defined 
capsule  is  formed.  In  this  condition  these  glandular  structures  of 
the  ovary  are  known  as  graafian  follicles.19 

Before  puberty,  these  graafian  follicles  are  small  vesicles  of-  a 
diameter  of  one  to  two  millimetres,  containing  the  large  unicellular 
ova.  Each  of  these  consists  of  an  envelope,  the  zona  pellucida  (also 
known  as  the  zona  radiata,  or  striated  membrane  of  the  ovum)  ;  an 
external  granular  mass  of  protoplasm,  the  viitellus  or  yolk ;  a  vesicu- 
lar, spherical  nucleus,  the  germinal  vesicle;  and  a  nucleolus,  which 
if  single  is  large  and  prominent,  the  macula  germinativa  or  germi- 
nal spot.  As  early  as  the  second  year  of  infancy  every  imaginable 
intermediate  stage_  bet  ween  the  primitive  follicle  and  the  fully-de- 
veloped vesicular  graafian  follicle  can  be  observed. 

19  It  is  by  a  certain  abuse  of  terminology  that  the  name  follicle  is  given  to  these 
structures  even  before  the  appearance  of  fluid  in  their  interior,  the  word 
folliculus  meaning  properly  a  little  bag  or  sack.  The  author's  limitation  of 
the  term  graafian  follicle  to  the  later,  full-grown  stage  of  these  structures, 
though  historically  accurate,  is  not  usual'  in  England.  Tr. 


58  THE  SEXUAL  LIFE  OF  WOMAN. 

At  the  time  of  puberty  certain  larger  follicles  are  always  to  be  dis- 
tinguished, which  have  moved  inward  toward  the  interior  layers 
of  the  ovary,  whereas  the  smaller  follicles  have  a  more  peripheral 
situation ;  thus,  according  to  Waldeyer,  we  observe  at  this  time  in 
a  section  of  the  ovary,  proceeding  from  without  inward,  first  the 
epithelium,  next  the  fibrous  tunic,  next  the  zone  of  younger  follicles, 
and  finally  the  zone  of  older  follicles.  According  to  Henle  and 
Waldeyer,  at  the  commencement  of  puberty,  there  are  in  each  ovary 
about  36,000  ova,  giving  a  total  for  the  two  of  72,000. 

In  the  further  course  of  development  of  the  graafian  follicles  at 
this  period,  the  most  advanced  now  reapproach  the  surface  of  the 
ovary,  so  that  a  fully-matured  follicle  comes  to  occupy  almost  the 
entire  thickness  of  the  cortical  substance,  and  may  even  give  rise 


FIG.  15. — Primitive  follicles. 

to  a  localized  bulging  of  the  surface  of  the  organ.  In  such  a  mature 
follicle,  which  has  attained  nearly  the  size  of  a  pea,  we  recognize 
an  outermost  connective-tissue  investment  (thcca  follicnli},  consist- 


THE  SEXUAL  EPOCH  OF  THE  MENARCHE.  59 

ing  of  condensed  ovarian  stroma,  in  which  two  layers  are  distin- 
guished, sometimes  called  simply  outer  tunic  and  inner  tunic,  some- 
times known  by  the  names  of  tunica  fibrosa  (outer)  and  tunica  pro- 
pria  (inner),  respectively;  within  this  is  the  cellular  layer  known 
as  the  nicnibrana  granulosa  (or  stratum  granulosum),  the  portion 
of  which,  now  greatly  enlarged,  immediately  surrounding  the  ovum 
is  known  as  the  disciis  proligcrus  (or  cumulus  ooplionis) ;  the  inter- 
space between  the  discus  proligerus  and  the  membrana  granulosa  is 
filled  with  a  clear  fluid,  the  liquor  folliculi.  In  consequence  of  the 
continued  increase  in  its  fluid  contents,  the  graafian  follicle  ulti- 
'mately  bursts  along  the  most  prominent  portion  of  the  superficial 
wall,  and  the  ovum  passes  out  through  the  rupture,  finding  its  way 
under  normal  conditions  into  the  Fallopian  tube  and  through  this 
into  the  uterus.  The  follicle  itself  then  undergoes  a  regressive 
metamorphosis,  forming  the  corpus  lit t cum,  the  rent  in  the  envelope 
of  which,  after  the  absorption  of  the  yellowish  semi-fluid  contents, 
undergoes  cicatrization.  Contemporaneously  with  this  development 
at  puberty  of  the  process  of  ovulation,  menstruation  also  for  the 
first  time  makes  its  appearance,  recurring  thenceforward  at  four- 
weekly  intervals  as  the  regular  catamenial  discharge. 

We  append  the  account  given  by  Pfauncnsticl  regarding  the 
ovarian  follicles.  He  writes :  "  In  correspondence  with  the  especial 
function  of  the  female  reproductive  gland,  which  is  to  bring  to  ma- 
turity and  to  evacuate  only  after  the  lapse  of  a  considerable  period 
and  at  successive  intervals,  the  ova  which  it  has  contained  from  the 
very  outset,  we  find  that  primitive  follicles  continue  to  exist  in  the 
ovary  up  to  the  very  end  of  the  period  of  sexual  activity,  though 
naturally  in  diminishing  numbers ;  and  the  size  and  shape  of  these 
primitive  follicles  remain  nearly  identical  throughout  the  various 
periods  of  life.  As  the  follicle  ripens,  the  epithelium  grows,  the  cells 
becoming  cubical  with  a  rounded  nucleus,  and  increasing  in  number 
by  cell-division,  so  that  several  layers  are  formed.  As  soon  as  these 
layers  are  three  or  four  in  number,  a  space,  at  first  slit-shaped,  forms 
in  the  epithelium  on  the  peripheral  surface  of  the  ovum ;  this  space 
is  filled  with  fluid,  known  as  the  liquor  folliculi ;  the  peripheral 
layer  of  cells,  the  membrana  granulosa,  is  thus  separated  from  the 
mass  of  epithelial  cells  immediately  enveloping  the  ovum,  the  discus 
proligerus,  which  is  situate  in  the  side  of  the  follicle  adjacent  to 
the  hilum  of  the  ovary.  By  the  increase  of  the  liquor  folliculi  the 
graafian  follicle  is  formed,  a  vesicle  the  envelope  of  which  is  formed 
by  the  multilaminar  membrana  granulosa,  whilst  in  the  pole  of  the 
vesicle  directed  toward  the  hilum  ovarii  is  the  ovum  imbedded  in 
the  mass  of  cells  forming  the  discus  proligerus,  a  mass  which  has 
the  form  of  a  truncated  cone.  The  liquor  folliculi  is  formed  by 


60  THE  SEXUAL  LIFE  OF  WOMAN. 

the  epithelium,  the  nuclei  of  which  disappear  by  chromatolysis  or 
by  simple  atrophy.,  whilst  the  cell-bodies  liquefy  in  consequence 
of  albuminous,  not  fatty,  degeneration  (Schottldnder).  Within  the 
epithelium  of  the  follicle  we  find  the  faintly  glistening  epithelial 
vacuoles  of  Fleming,  likewise  cells  which  liquefy  and  assist  in  in- 
creasing the  bulk  of  the  liquor  folliculi.  This  liquor  is  a  thin,  serous 
fluid,  and  contains  albumin.  *  *  *  Every  graafian  follicle  has  a 
bilaminar  investing  membrane,  which  is  formed  by  the  ovarian 
stroma.  *  *  *  The  ovum  of  the  growing  follicle  increases  in 
size  very  slowly  indeed,  attaining  on  the  average,  according  to 
Nagel,  a  diameter  of  165  to  170  p,  it  retains  its  zona  pellucida, 
the  greater  part  of  the.  protoplasm  of  the  cell  is  transformed  into 
dentoplasm  (food-yolk,  or  yolk-granules),  the  nucleus  assumes  an 
eccentric  position.  Between  the  zona  pellucida  and  the  cell-body 
a  narrow  perivitelline  space  appears.  The  ovum  is  then  full-grown, 
but  not  yet  fully  prepared  for  fertilization;  for  this,  maturation  is 
required,  certain  changes  in  the  germinal  vesicle,  which  occur  after 
the  bursting  of  the  follicle.  *  *  As  a  rule  each  follicle  contains 
a  single  ovum.  But  two  and  even  three  ova  have  beyond  doubt  been 
observed  in  one  follicle." 

According  to  Waldeycr,  the  bursting  of  the  follicle  is  not  to  be 
regarded  as  dependent  upon  a  sudden  rise  of  pressure  in  its  interior, 
but  as  the  result  of  a  gradual  ripening  process.  At  the  deepest 
pole  of  the  follicle,  which  in  the  course  of  its  development  has 
now  approached  the  surface  of  the  ovary,  an  exuberant  growth  takes 
place  in  the  internal  layer  (tunica  propria)  of  the  theca  folliculi, 
with  a  profuse  formation  of  new  vessels.  Here  numerous  "  epith- 
elioid  "  cells,  the  "  lutein-cells,"  make  their  appearance.  In  conse- 
quence of  this  proliferation  of  the  lutein-cells,  the  contents  of  the 
follicle  are  gradually  pressed  toward  the  "  stigma,"  the  superficial 
pole  of  the  follicle,  and  the  follicle  itself  is  pushed  toward  the  sur- 
face until  it  finally  comes  into  contact  with  the  germinal  epithelium. 
Meanwhile  the  follicular  epithelium  undergoes  fatty  degeneration, 
alike  in  the  membrana  granulosa  and  in  the  discus  proligerus.  In 
consequence  of  the  proliferation  of  the  lutein-cells,  on  the  one  hand, 
and  the  fatty  degeneration  of  the  epithelium,  on  the  other,  the  follicle 
opens  at  its  weakest  point,  the  stigma,  and  the  ovum  is  extruded, 
with  the  liquor  folliculi,  and  a  number  of  cells  belonging  to  the 
follicular  epithelium.  (To  illustrate  these  changes  we  have  bor- 
rowed FIGS.  15,  16,  and  17  from  the  monograph,  by  Pfannenstiel  on 
Diseases  of  the  Ovary,  in  J.  Veils'  Handbook  of  Gynecology.} 

The  ovaries,  which  in  the  new-born  female  infant  are  flattened, 
ribbon-like  bodies  one-half  to  one-centimeter  (0.2  to  0.4")  in  length, 
and  in  childhood  are  cylindrical,  with  a  perfectly  smooth  surface, 


THE  SEXUAL  EPOCH  OF  THE  MENARCHE.  6l 

assume  at  the  time  of  puberty  a  more  or  less  flattened  form.  Dur- 
ing the  menarche  they  have  an  elongated  oval  shape,  flattened  from 
side  to  side,  their  average  length  being  2.5  to  5.0  centimetres  (i  to 
2"),  width  1.5  to  3.0  centimetres  (0.59  to  1.18"),  thickness  0.6  to 
1.4  centimetres  (0.24  to  0.55"),  weight  5  to  8  grammes  (77  to  123 
grains).  After  the  repeated  occurrence  of  ovulation,  the  surface  of 
the  ovary  becomes  more  and  more  uneven,  being  thickly  covered 
with  fossae  or  scar-like  fissures. 


FIG.  16. — Ripening1  follicles. 

The  vagina  during  virgin  girlhood  is  narrow,  and  its  mucous 
surface  is  beset  with  numerous  rugae,  which  may  be  plainly  felt  as 
well  as  seen.  The  calibre  of  the  vagina  is  proportionately  less  the 
younger  the  girl.  The  examining  finger  is  gripped  by  the  vaginal 
wall  as  by  an  india-rubber  tube  (Maschka).  The  vaginal  portion 
of  the  cervix  is  felt  in  the  form  of  a  truncated  cone,  with  a  smooth 
surface,  rather  dense  in  consistence ;  the  external  os  opens  at  the 
bottom  of  a  small  depression  on  its  surface,  in  the  form  of  a  short 
oval,  the  long  axis  of  which  is  transversely  directed.  Shortly  before 
the  menarche,  Bartholin's  glands  become  noticeable  on  either  side 
of  the  lower  end  of  the  vagina  between  the  sphincter  muscles. 

The  clitoris  in  many  cases  attains  a  very  large  size,  and  this  is  apt 
to  lead  to  sexual  malpractices.  According  to  Hyrtl,  in  southern 
countries  the  clitoris  is  larger  than  in  temperate  and  cold  climates. 
In  the  women  of  Abyssinia  and  among  the  Mandingoes  and  the 
Ibboes,  the  size  is  portentous,  and  amongst  the  first-named,  cir- 
cumcision of  females  is  a  customary  operation.  It  is  said  that  fe- 
male slaves  belonging  to  these  races  are  greatly  esteemed  by  the 


62  THE  SEXUAL  LIFE  OF  WOMAN. 

ladies  of  the  harem,  and  are  eagerly  sought  for.  In  the  anatomico- 
pathological  museum  at  Prague  there  is  a  preparation  of  the  female 
genital  organs  with  a  clitoris  as  large  as  the  penis  of  a  full-grown 
man. 


FIG.  17. — Graafian  follicles. 

Sonini  describes  "  as  peculiar  to  women  of  Egyptian  or  Koptic 
descent,  the  presence  of  a  thick,  fleshy,  but  soft  and  pendent  out- 
growth in  the  pubic  region,  completely  covered  with  hair,"  which 
he  compares  to  the  hanging  caruncle  on  the  bill  of  the  male  turkey. 
This  appendage  becomes  thicker  and  longer  with  advancing  years. 
Sonini  found  such  an  appendage  one-half  inch  in  length  in  a  girl  of 
eight  years,  one  of  more  than  four  inches  in  a  woman  of  twenty  to 
twenty-five  years.  Circumcision  in  girls  consists  in  the  removal  of 
this  outgrowth,  which  hinders  copulation ;  in  that  part  of  the  world 
the  operation  is  usually  effected  in  the  seventh  or  eighth  year,  just 
before  puberty. 

The  circumcision  of  girls  as  practiced  by  Mahommedan  peoples 
in  Africa  is  said  by  Ploss  and  Barteh  to  consist  in  abscission  of  the 
labia  minora,  the  clitoris,  and  the  prseputium  clitoridis.  Brchm  is 
of  opinion  that  the  object  of  the  operation  is  to  diminish  the  in- 
tensity of  the  sexual  impulse,  so  overpowering  among  these  races ; 
but  others  believe  that  the  great  enlargement  of  the  clitoris  and  the 


THE  SEXUAL  EPOCH  OF  THE  MENARCHE.  63 

labia  minora  usual  in  those  countries  is  regarded  as  a  serious  defect 
in  beauty,  a  defect  removed  by  the  operation ;  whilst  others  again 
hold  that  the  circumcision  is  required  for  the  removal  of  the  hin- 
drance to  copulation  presented  by  the  abnormally  large  clitoris. 
Closely  related  to  the  operation  of  circumcision  in  females,  according 
to  Ploss  and  Bartcls,  is  the  custom  peculiar  to  Africa  of  infibulation, 
wherein,  after  a  preliminary  cutting  operation  like  that  for  circum- 
cision, the  fresh  wound  surfaces  are  brought  into  accurate  opposi- 
tion, either  by  sutures  or  by  appropriate  bandages,  so  that  when 
cicatrization  occurs  the  vulval  cleft  is  closed  except  for  a  very  small 
aperture.  The  object  of  infibulation  is  to  enforce  on  girls  complete 
abstinence  from  sexual  intercourse.  (Before  marriage,  the  vulval 
cleft  is  reopened  to  an  extent  corresponding  with  the  size  of  the 
genital  organs  of  the  future  husband;  and  when  pregnancy  occurs, 
the  opening  is  still  further  enlarged  before  parturition ;  but  after 
that  event,  the  wound  surfaces  are  refreshed,  and  the  whole  opening 
is  once  more  closed).  On  the  other  hand,  in  many  savage  tribes, 
elongation  of  the  labia  minora  and  the  clitoris  is  artificially  under- 
taken from  the  earliest  years  of  girlhood,  this  elongation  being  re- 
garded as  a  beauty. 

The  parts  of  the  external  reproductive  organs  of  the  female  con- 
cerned in  sexual  sensation,  first,  described  as  such  by  Kobclt, 
are  already  fully  developed  at  the  time  of  the  menarche.  Of  these 
parts  a  small  portion  only,  the  glans  clitoridis,  is  visible  externally, 
surrounded  by  the  prseputium  clitoridis,  a  prolongation  of  the  labia 
minora,  which  passes  round  the  front  of  the  clitoris,  and  sends 
from  each  side  a  fine  process  behind  the  glans  to  become  attached  to 
its  under  surface,  forming  the  frsenum  of  the  clitoris.  The  erectile 
apparatus  of  the  external  genitals  is  formed  by  the  corpora  cavernosa 
clitoridis.  As  two  delicately  constructed  trabecular  masses  of 
erectile  tissue,  the  crura  of  the  clitoris,  these  are  attached  on  either 
side  to  the  inferior  or  descending  rami  of  the  pubic  bones ;  at  first 
passing  upwards  parallel  to  the  bones,  they  subsequently  curve  down- 
ward, as  they  converge  and  unite  to  form  the  body  of  the  clitoris ; 
these  masses  of  erectile  tissue  embrace  the  sides  and  the  front  of 
the  lower  extremity  of  the  vagina.  This  erectile  apparatus,  when 
the  supply  of  arterial  blood  is  greatly  accelerated  and  at  the  same 
time  the  outflow  of  venous  blood  is  diminished,  becomes  distended 
with  blood,  enlarged  and  stiffened ;  the  process  of  erection  plays  an 
important  part,  as  we  shall  explain  more  fully  later,  in  the  produc- 
tion of  sexual  excitement  and  sexual  pleasure  during  the  act  of 
copulation. 

In  the  virgin  and  in  the  earlier  phases  of  the  sexual  life,  the 
hymen  is  so  characteristic  an  organ  that  its  more  minute  descrip- 
tion would  seem  desirable. 


64 


THE  SEXUAL  LIFE  OF  WOMAN. 


The  hymen,  a  fold  of  mucous  membrane,  springing  from  the 
periphery  of  the  vaginal  orifice,  separates  as  a  perforated  diaphragm 
the  vagina  from  the  vulva.  Between  the  two  epithelial  layers  of 
which,  as  a  fold  of  mucous  membrane,  the  hymen  consists,  is  a  sup- 
porting layer  of  connective  tissue  of  variable  strength;  in  other  re- 
spects the  mucous  membrane  of  the  hymen  has  the  same  structure 
as  the  mucous  membrane  of  the  vagina.  On  its  inner  surface  the 
rugae  and  folds  of  the  vaginal  mucous  membrane  are  prolonged. 
The  shape  of  the  hymen  is  very  variable ;  most  commonly  its 
aperture  is  more  or  less  central,  so  that  the  hymen  has  a  ringed  or 
semilunar  shape. 

In  the  new-born  female  infant,  the  hymen  has  the  appearance  of 
a  tubular  stopper  closing  the  lower  end  of  the  vagina ;  according  to 
Dohrn  it  exhibits  as  a  rule  one  of  three  typical  forms:  Hymen 
anmtlaris,  denticnlatns,  et  Hnguiformis;  the  annular,  the  denticulate, 
and  the  lingnifonn  (or  lingnlifonn}  hymen.  The  transverse  ridges 
on  the  inner  surface  of  the  hymen,  prolongations  of  the  rugose 
columns  of  the  vagina,  are  strongly  developed.  During  the  girl's 
further  growth,  in  association  with  the  enlargement  of  the  vagina," 
the  hymen  undergoes  important  changes  in  form  and  structure. 
Its  border  becomes  thinner  and  more  tense ;  and  in  the  virgin  at  the 
time  of  the  menarche,  the  annular  hymen  is  the  fundamental  type, 


Fie.  18. — Annular  Hymen. 


FIG.  19. — Annu'ar  Hymen 


subject,  however,  to  extensive  variations.  In  most  cases,  at  any 
rate,  the  aperture  in  the  hymen  is  more  or  less  centrally  situated ; 
very  commonly,  however,  this  opening  is  crescentic,  when  we  have  a 


THE  SEXUAL  EPOCH  OF  THE  MENARCHE. 


semilunar  hymen,  the  height  of  the  border  posteriorly  being  much 
greater  than  anteriorly.  The  consistency  of  the  hymen,  its  extensi- 
bility, and  its  thickness,  are  as  variable  as  its  shape. 


pig.  20. Semilunar  Hymen.  FIG.  21. — Annular  Hymen  with  con- 

genital Symmetrical  Indentations. 


Fig.  22.— Fimbriate  Hymen.     FIG.  23.— Deflorated  Fimbriate  Hymen. 

In    the  normal   position   of  the   reproductive  organs  the   hymen 
has  very  rarely  the  appearance  of  a  tense  membrane;  as  a  rule  it 


66  THE  SEXUAL  LIFE  OF  WOMAN. 

is  folded  up,  and  becomes  plainly  manifest  only  when  the  genital 
organs  are  stretched.  The  margin  of  the  hymeneal  aperture,  as  a 
close  examination  shows,  is  sometimes  sharp  and  regular,  sometimes 
tabulated,  with  small  congenital  notches.  These  congenital  notches 
are  to  be  distinguished  from  the  lacerations  resulting  from  deflora- 
tion by  the  fact  that  the  former  have  a  smooth  border,  which  is  of 
the  same  consistency  as  the  general  substance  of  the  hymen.  In  some 
instances  -the  border  of  the  aperture  in  the  hymen  is  beset  with  small, 
fine  villi  (villous  hymen). 

The  common  varieties  of  the  hymen  are  thus  classified  by 
Maschka: 

1.  The  annular  hymen,  in  which  the  membrane  when  stretched  is 
seen  to  have  a  rounded  aperture,  which  may  be  central  or  eccentric ; 
very  often,  indeed,  the  aperture  is  more  toward  the  upper  half  of 
the  hymen,  in  which  case  it  is  not  always  circular,  but  frequently 
rather  ovoid  in  shape. 

2.  The  sciiiihinar  or  cresccntic  hymen,  in  which  the  aperture  is 
eccentrically  placed  in  the  upper  half  of  the  membrane,   in  such 
a  manner  that  the  hymen  exhibits  a  wide  surface  below  the  aperture, 
which  surface  narrows  at  either  side  as  it  passes  upwards  until  it 
disappears,  the  two  sides  failing  to  reunite  above  the  aperture. 

3.  The  heart-shaped  or  cordiform  hymen,  the  general  shape  of 
which  may  be  circular,  ovoid,  or  even   semilunar,  but  in   which 
from  the  middle  of  the  upper  or  lower  margin  a  three-cornered 
tongue  projects  across  the  aperture,  which  is  thus  given  the  form 
of  the  conventional  heart  of  a  pack  of  cards. 

4  The  infundibi'liform  hymen  has  the  form  of  a  small  project- 
ing funnel  resembling  in  appearance  the  invaginated  end  of  the  finger 
of  a  glove. 

Maschka  refers  also  to  the  rare  condition  in  which  the  hymen 
is  sometimes  said  to  be  absent.  As  a  matter  of  fact,  however,  in 
such  cases,  it  is  represented  by  a  very  narrow  annular  eminence,  the 
genitals  being  in  other  respects  normal.  The  smooth  character  of 
the  eminence  will  serve  to  differentiate  it  from  the  remains  of  a 
destroyed  hymen.  Other  rare  forms  are : 

1.  The    impcrforate    hymen,    an    occlusive    membrane,    entirely 
blocking  the  vaginal  orifice.     In  some  cases,  however,  the  hymen 
is  not  absolutely  imperforate,  a  very  small,  punctiform  aperture 
being  present. 

2.  The  cribriform  hymen,  a  hymen  which  is  "  imperforate  "  in 
the  sense  that  there  is  no  opening  of  a  size  approaching  the  normal, 
but  in  which  several  minute  apertures  are  present. 

3.  The  septate,  bridged  or  divided  hymen  (hymen  bifencstratus, 
etc.),  exhibits  a  strip  of  mucous  membrane,  most  commonly  running 


THE  SEXUAL  EPOCH  OF  THE  MENARCHE. 


67 


directly   from   before   backward,   occasionally,   however,   somewhat 
obliquely,  across  the  aperture  in  the  membrane,  which  is  thus  di- 


FIG.  24.— Septate  Annular  Hymen.         PIG.  25,— Septate  Semilunar  Hymen. 


FIG.  26. — Extremely  tough  Annular         FIG.  27. —  Septate       Hymen      with 
Hymen,    with    an  obliquely    dis-  Apertures  of  unequal  size, 

posed   Septum. 

vided  into  two  equal  or  unequal  parts.  In  some  instances  the 
process  that  bridges  the  aperture  of  the  hymen  is  expanded  in  the 
vertical  plane  to  form  a  septum  which  projects  for  some  distance 
into  the  vagina. 


68 


THE  SEXUAL  LIFE  OF  WOMAN. 


4.  The    lobaic,    lobulatcd,    or    labiate    hymen,     which    consists 
of  several   (two  to  four)   lobes  on    either    side,    each  overlapping 


FIG.  28. —  Septate  Hymen  with 
Apertures  of  unequal  size. 


FIG.  29. —  Hymen  with  rudimentary 
Septum. 


the  next  like  the  tiles  in  a  roof,  whilst  the  aperture  between  the 
two  sides  has  the  form  of  an  antero-posterior  slit   (FiG.  37)  ;  in 


. —  Hymen  with  posterior  rudi-       FIG.  31. —  Labiate    Hymen    with 
mentary  Septum.  posterior  rudimentary  Septum. 


FIG.  30. —  Hymen  with 

„    o 


some  cases  the  lobes  of  a  lobulated  hymen  are  so  disposed  that 
the  membrane  has  the  appearance  of  a  fold  of  mucous  membrane 
with  a  central  furrow. 


THE  SEXUAL  EPOCH  OF  THE  MENARCHE. 


69 


It  is  obvious  that  an  imperforate  or  cribriform  hymen,  by  the 
hindrance  it  offers  to  the  passage  of  the  menstrual  discharge,  is 


FIG.    32. —  Hymen  with  anterior     FIG.  33. —  Hymen  with  anterior  rudi- 
rudimentary  Septum.  mentary  Septum  projecting  in  a 

opiniform  Manner. 

liable  at  the  time  of  the  menarche,  and  as  soon  as  menstruation  be- 
gins, to  give  rise  to  serious  disorder  and  to  pathological  states. 


FIG.  34. —  Hymen  with  ante-    FIG.    35. —  Hymen  FIG.  36, —  Hymen  in  which 

ri or  and  posterior  rudimen-      with  filiform  pro-  there  are  two  symmetri- 

tary  Septa.                                   cess      projecting  cally    disposed    thinned 

from  the  anterior  areas.    The  left  of  these 

margin.  is  perforated. 

The  illustrations  we  append,  showing  the  various  forms  of  the 
hymen,  are  taken  from  von  Hoffmann's  Handbook  of  Medical  7wrt.fr- 
prudence.  (Fics.  18-45.) 


THE  SEXUAL  LIFE  OF  WOMAN. 


In  some  cases  the  hymen  is  exceedingly  thin  and  delicate,  so  that 
it  is  liable  to  be  torn  if  handled  at  all  roughly;  in  other  cases,  on 


FIG.  37, —  Very  un- 
usual form  of 
Hymen. 


FIG.  38. —  Semilunar  Hymen  FIG.  39.— Deflorated  Semilunar 
with  cicatrized  Lacera-  Hymen  with  laterallv  dis- 
tions  in  its  Border.  posed  Symmetrical  lacer- 

ations. 


FIG.  40. — Deflorated  Annular 
Hymen  with  several  cica- 
trized Lacerations. 


FIG.  41. —  A.  Septate  Hymen  in  which  Deflora- 
tion has  been  effected  through  one   of  the 
Apertures.     U.  Urethra.      Cl.  Clitoris.     1 1 
Cicatrized  margin.     C.  Septum.      B.  Lateral 
View  of  Septum. 


the  contrary,  it  may  be  very  firm,  thick,  and  fleshy,  interlaced  with 
strands  of  connective  tissue  and  muscle,  so  that  it  forms  a  veritable 
cuirass  for  the  protection  of  physical  virginity. 


THE  SEXUAL  EPOCH  OF  THE  MENARCHE. 


As  signs  of  virginity  in  the  female,  a  knowledge  of  which  is 
required,  not  only  for  the  purposes  of  medical  jurisprudence,  but 


FIG,  42. — Deflorated  Septate   Hymen.     FIG.  43. — Hvmen  with  larger  anterior  and 

smaller  posterior  Apertures. 


FIG.  44. —  Carunculae  Myrtiformes        FIG.  45. — Vaginal    Inlet    of    a    Multipara, 
in  a  Primipara.  without  Carunculae  Myrtiformes.      Slight 

Prolapse    of   anterior   and   posterior  Va- 
ginal Walls 


72  THE  SEXUAL  LIFE  OF  WOMAN. 

for  various  other  reasons,  we  may  enumerate  the  following  ana- 
tomical characteristics  of  the  genital  organs.  The  labia  majora 
are  elastic  in  consistence  and  are  in  close  apposition  with  one  an- 
other; the  labia  minora  or  nymphae  are  covered  by  the  labia  majora 
and  are  but  little  pigmented;  the  vestibule  and  the  vaginal  orifice 
are  narrow,  and  the  vagina  itself  is  narrow,  tense,  and  markedly 
rugose;  the  hymen  is  normal  and  uninjured  (this,  of  course,  is  the 
most  trustworthy  of  all  the  signs  of  virginity)  ;  the  breasts  have 
the  virgin  conformation.  In  opposition  to  the  plea  that  the  hymen 
can  be  destroyed  by  other  causes  than  defloration,  as  by  a  fall, 
especially  a  fall  which  brings  the  external  genitals  in  contact  with 
some  hard  body,  or  by  diphtheritic,  variolous,  or  syphilitic  ulcera- 
tion,  Maschka  maintains  that  such  occurrences  are  among  the  great- 
est rarities. 

On  the  other  hand  it  is  sufficiently  well  known  that  the  presence 
of  an  uninjured  hymen  affords  no  certain  assurance  of  actual  vir- 
ginity. Cases  enough  are  recorded,  both  in  older  and  more  recent 
medical  literature,  in  which  even  pregnancy  occurred  in  women  in 
whom  the  hymen  had  remained  intact,  the  explanation  being  that 
during  copulation  penetration  of  the  penis  had  failed  to  occur,  the 
semen  being  ejaculated  on  the  vulva.  Scanzoni  and  Zii'dfcl  have 
recorded  cases  in  which  the  intact  hymen  offered  a  hindrance  to  par- 
turition. The  first-named  author  explains  these  occurrences  by  the 
Assumption  that  the  hymen  was  so  stout  that  the  penis  was  unable  to 
rupture  it.  Vcit  remarks  that  both  male  and  female  youth,  in  these 
days  of  the  continued  advance  of  knowledge,  are  well  acquainted 
with  coitus  sine  iininissione  penis,  and  that  very  frequently  a  woman 
who  is  informed  that  she  is  pregnant  makes  answer  that  this  is  im- 
possible, her  paramour  having  assured  her  that  pregnancy  could  not 
occur.  On  the  other  hand,  cases  are  met  with  in  which  the  aperture 
in  the  hymen  is  a  very  large  one,  so  large  that  the  penis  can  penetrate 
to  the  vagina  without  lacerating  the  membrane. 

Broudardel  reports  a  case  of  rape  in  which  the  lacerated  hymen 
healed  so  completely  that  an  expert  maintained  the  integrity  of  the 
membrane,  until  another  pointed  out  the  fine  scar. 

In  general,  that  we  may  be  assured  of  the  existence  of  virginity, 
we  must  find  the  hymen  uninjured;  and,  on  the  other  hand,  we 
must  regard  the  laceration  of  the  membrane,  unless  known  to  be  the 
result  of  gynecological  examination  or  other  manipulation,  as  a 
proof  of  defloration. 

In  ancient  times  among  savage  races  the  integrity  of  the  hymen 
was  prized  as  a  proof  of  virginity,  and  in  the  Bible  also  great  stress 
is  laid  on  this  sign  in  connection  with  defloration,  and  its  absence 
was  even  regarded  as  a  ground  for  the  death  punishment  (Deut. 


THE  SEXUAL  EPOCH  OF  THE  MENARCHE. 


73 


xxii,  21 ).     But  amongst  other  races  the  hymen  was  held  in  no  par- 
ticular esteem  as  a  token  of  virginity. 

In  ancient  times,  and  even  at  the  present  day  in  the  Philippine 
Islands,  the  Ladrone  Islands,  and  certain  other  islands  of  the  Poly- 
nesian Archipelago,  also  among  many  African  tribes,  the  right  of 
defloration  belonged,  not  to  the  bridegroom,  but  to  every  man  be- 
longing to  the  same  tribe;  sometimes  on  the  bridal  night  all  the 
men  of  the  tribe  had  access  to  the  bride,  the  bridegroom  coming 
last,  but  thenceforward  having  undisputed  possession  of  his  wife. 


Nip- 
ple or 
ma- 
milla 


Areola 

Supernumerary 
mamma 

FIG.  46.—  Mamma,  the  breast  of  a  virgin  aged  eighteen    years.      (From 
Toldt:     Atlas  of  Human  Anatomy.— Rebman  Company,  New  York.) 

Amongst  certain  other  tribes  a  similar  custom  prevails,  differing 
however  in  this  respect,  that  the  rite  of  defloration  is  performed  by 
a  priest  or  by  one  of  the  chiefs  of  the  tribe.  In  mediaeval  Europe, 
again,  the  great  landed  proprietors  exercised  the  well-known  jus 
prium  noctis  or  droit  du  seigneur. 

In  girls  at  the  time  of  the  menarche  who  have  long  practiced 
masturbation,  some  of  the  following  indications  of  the  habit  will 


74  THE  SEXUAL  LIFE  OF  WOMAN. 

be  found :  Elongation,  redness,  and  general  enlargement  of  the 
clitoris;  elongation  and  thickening  of  the  nymphse,  which  are  also 
of  a  tough  consistency  and  deeply  pigmented ;  flaccidity  of  the  labia 
majora;  redness  of  the  vaginal  orifice;  flaccidity  of  the  hymen, 
which  also  may  exhibit  lacerations,  caused  by  the  forcible  introduc- 
tion of  the  finger  or  of  some  hard  foreign  body. 

Not  until  the  time  of  the  menarche  do  the  breasts  attain  the 
hemispherical  form  which  constitutes  one  of  the  graces  of  young 
womanhood,  and  at  the  same  time  these  organs  assume  a  firm,  elas- 
tic consistency ;  their  size  of  course  varies  in  different  individuals. 
The  nipple  now  has  a  rose-red  color,  darker  in  brunettes  than  in 
blondes;  it  is  usually  small,  sometimes  quite  inconspicuous,  being 
withdrawn  into  a  cutaneous  furrow.  The  two  breasts  when  re- 
garded from  the  front  are  seen  to  diverge  from  the  longitudinal  axis 
of  the  body.  In  some  cases  even  in  childhood,  before  the  time  of  the 
menarche,  the  breasts  are  powerfully  developed,  being  as  large  as 
an  apple  or  larger.  This  depends  on  climate,  race,  and  sexual  ex- 
citement ;  as  regards  the  last  of  these,  early  sexual  stimulation  pro- 
motes premature  mammary  development. 

Although  it  is  unusual  for  any  secretion  to  appear  in  the  mammary 
gland  before  the  occurrence  of  pregnancy,  cases  have  certainly  been 
observed  in  which  the  breasts  of  virgins  secreted  a  milk-like  fluid, 
especially  in  consequence  of  sexual  excitement  or  during  menstrua- 
tion. Thus  Maschka  observed  in  a  girl  the  condition  of  whose 
genital  organs  showed  her  to  be  a  virgo  intacta  that  pressure  on  the 
breast  caused  a  few  drops  of  an  opalescent  fluid  having  the  appear- 
ance of  milk  to  exude  from  the  nipple.  She  acknowledged  that 
amatory  relations  had  long  subsisted  between  her  and  a  lover  who 
was  in  the  habit  of  handling  her  breasts,  and  that  this  always 
produced  strong  sexual  excitement.  Hofmann  also  reported  that  in 
two  virgins  who  died  during  menstruation  he  was  able  to  express 
a  drop  of  milk  from  the  breast. 

The  most  important  indication  of  the  general  changes  occurring 
in  the  external  and  internal  genital  organs,  the  proof  that  the 
young  woman  has  become  fitted  for  the  fulfilment  of  her  reproduc- 
tive vocation,  is  the  appearance  of  menstruation,  a  sanguineous  dis- 
charge from  the  genital  organs  recurring  every  four  weeks  as  the 
•external  manifestation  of  the  internal  process  of  ovulation. 

The  anatomical  changes  that  have  already  been  described  as 
occurring  in  the  genital  organs  at  the  time  of  the  menarche  will 
serve  to  elucidate  the  numerous  reflex  processes  that  manifest  them- 
selves at  this  period  of  life  in  so  many  departments  of  vital  activity. 

It  is  especially  the  extensive  developmental  processes  in  the  ovary, 
influencing  the  nerves  of  that  organ,  which  give  rise  to  centri- 


THE  SEXUAL  EPOCH  OF  THE  MENARCHE.  75 

petal  stimuli  and  evoke  reflex  manifestations.  In  the  working  of 
the  circulatory  system,  such  influences  are  apparent ;  and  during  the 
menarche,  some  time  already  before  the  first  onset  of  menstruation, 
variations  occur  in  the  blood-pressure,  and  these  during  menstrua- 
tion take  the  form  of  a  typical  undulatory  curve. 

Inner  border* 
Pectoral  fascia* 

Pectoralis  major  muscle 
Panniculus  adiposu& 

Sk'n 

Lobules  of  the  bre 
Lobes  of  the  breas 


Nipple  or  mamilla  -x 


Galactophorous  or 
mamillary  ducts 


Ampulla?  or  sinuses 
of  the  ducts 

Body  of  the  breast 


Outer  border 


FIG.  47. —  Horizontal  section  through  the  female  breast.       (From  Toldt: 
Atlas  of  Human  Anatomy. —  Rebman  Company,  New  York.) 

Thus  it  becomes  comprehensible  that  even  in  healthy  girls,  the 
first  appearance  of  the  catamenia  and  likewise  the  expectation  of 
the  flow  induce  a  certain  modification  and  alteration  in  the  whole 
nature  and  disposition.  Girls  often  lose  their  previous  cheerful  and 
lively  character,  becoming  quiet,  self-absorbed,  sometimes  even 
melancholy;  they  are  disinclined  for  study,  have  a  repugnance  to 
all  sustained  physical  or  mental  activity,  become  annoyed  and  snap- 
pish on  slight  occasion,  are  restless  at  night,  consider  themselves  to 
be  ailing,  and  so  on.  During  the  first  menstruation  girls  commonly 
appear  pale  and  anxious,  they  have  blue  lines  beneath  the  eyes,  the 
face  has  a  tired  aspect,  the  movements  lack  energy,  and  a  general 
want  of  tone  combined  with  an  abnormal  irritability  may  be  noticed. 
Some  days  before  the  first  menstruation,  the  vulva,  the  labia  majora 


76  THE  SEXUAL  LIFE  OF  WOMAN. 

and  minora,  and  the  vaginal  mucous  membrane,  are  swollen,  the 
clitoris  becomes  conspicuous  in  consequence  of  erectile  processes,  a 
slight  secretion  appears  in  the  genital  passage,  and  the  breasts  be- 
come sensitive  and  slightly  turgid.  The  urine  deposits  a  thick 
sediment,  and  occasionally  severe  strangury  is  observed.  In  many 
cases,  also,  digestive  disturbances  occur,  loss  of  appetite,  constipa- 
tion, or  a  tendency  to  diarrhoea. 

The  first  menstruation  usually  lasts  four  or  five  days.  On  the 
first  day  the  discharge  is  blood-stained  mucus,  thereafter  becoming 
sanguineous.  In  some  cases,  the  bleeding  at  the  first  menstruation 
is  profuse  and  of  long  duration. 

It  is  not  always  after  the  first  menstruation  that  the  subsequent 
discharges  follow  at  the  regular  intervals  of  four  weeks.  In  deli- 
cate, anaemic  girls  the  second  menstruation  may  not  occur  till  sev- 
eral months  have  elapsed  after  the  first ;  less  often  the  second  men- 
struation ensues  a  fortnight  after  the  first,  or  even  earlier. 

At  the  time  of  the  menarche  the  sexual  impulse,  which  has  hitherto 
been  dormant,  becomes  strongly  developed.  It  is  evoked  at  this  time 
of  life  by  the  anatomico-physiological  changes  undergone  by  the  re- 
productive glands ;  the  stimulus  aroused  by  these  processes  in  the 
ovary,  being  conducted  to  the  brain,  awakens  passion.  At  the  same 
time  the  observation  of  the  growth  of  the  hairy  covering  on  the 
genital  organs,  the  development  of  the  breasts,  and  the  appearance 
of  menstruation,  tend  to  arouse  erotic  presentiments.  The  reading 
of  romances,  conversations  with  'female  friends,  and  observation  of 
the  conduct  of  full-grown  persons,  convert  these  presentiments  into 
clear  ideas,  and  excite  the  impulse  to  the  production  of  passionate 
sexual  sensations,  the  sexual  impulse.  How  far  these  stimuli  arising 
from  the  reproductive  apparatus  are  encouraged  and  accentuated, 
on  the  one  hand,  or  repressed  and  diminished,  on  the  other,  depends 
on  external  impressions  of  various  kinds.  The  environment  is  the 
determinant  for  the  further  transformation  of  the  as  yet  undiffer-. 
entiated  sexual  impulse  into  the  fully-developed  copulative  and  re- 
productive impulses. 

In  his  work  on  the  Physiology  of  Lore,  Mantegazza  describes  the 
yearning  and  stress  of  the  awakening  sexual  life,  arising  out  of  the 
presentiments,  hazy  sensations,  and  impulses,  which  are  felt  in  the 
very  earliest  period  of  the  developmental  phase  known  as  puberty. 

In  general,  in  a  young  girl  during  the  menarche,  the  sexual  im- 
pulse manifests  itself  rather  in  the  form  of  semi-conscious  reverie, 
of  platonic  love.  The  adolescent  girl  exercises  her  imagination  with 
the  circumstances  of  her  chaste  love,  her  mind  turns  to  this  sub- 
ject when  in  solitude,  her  mood  is  apt  to  become  melancholy,  and 
it  is  the  perusal  of  equivocal  novels,  or  the  educational  assistance  of 


THE  SEXUAL  EPOCH  OF  THE  MENARCHE.  77 

sexually  experienced  female  friends,  that  transforms  the  sexual  im- 
pulse to  a  vivid  flame. 

Some  authors  believe  that  a  sign  of  the  awakening  of  the  sexual 
impulse  when  directed  toward  some  particular  man  is  a  change  of 
color  on  the  part  of  the  girl  when  she  sees  this  individual  or  hears 
him  spoken  of.  Palpitation  of  the  heart  comes  on,  the  pulse  is  in- 
creased in  frequency,  the  respiration  also,  and  the  voice  fails.  In 
this  manner,  it  is  asserted,  Galen  discovered  the  love  of  a  Roman 
lady,  Justa,  for  the  dancer,  Pylades. 

The  psychological  reaction  of  the  sexual  impulse  at  the  time  of 
puberty  manifests  itself,  as  von  Krafft-Ebing  points  out,  in  manifold 
ways,  common  to  all  of  which,  however,  is  the  emotional  state  of 
the  mind,  and  the  need  that  the  strange  and  new  feelings  now  ex- 
perienced should  find  some  objective  centre  of  interest.  Such  ob- 
jective and  emotional  interests  lie  ready  to  hand  in  religion  and 
poetry,  both  of  which,  after  the  period  of  sexual  development  is  at 
an  end,  and  the  originally  incomprehensible  desires  and  impulses 
have  received  an  explanation,  continue  to  have  intimate  relations 
with  the  world  of  sexual  experience.  Any  one  who  doubts  this  must 
be  reminded  of  the  frequency  with  which  religious  fanaticism  makes 
its  appearance  at  the  time  of  puberty.  No  less  influential  is  the 
sexual  factor  in  the  awakening  of  aesthetic  feelings.  This  world  of 
the  ideal  opens  itself  at  the  time  when  the  development  of  the  sexual 
processes  begins.  *  *  *  The  love  of  early  youth,  continues  von 
Krafft-Ebing,  has  a  romantic,  idealizing  tendency.  In  its  first  mani- 
festations it  is  platonic,  and  willingly  exercises  itself  in  poetry  and 
history.  But  as  the  sensibility  awakens,  the  danger  arises  that  this 
passion,  with  its  idealizing  power,  will  be  transferred  to  persons  of 
the  opposite  sex  who  in  intellectual,  physical,  and  social  relations 
are  by  no  means  all  that  could  be  wished.  Hence  proceed  misal- 
liances, elopements,  and  seductions,  with  the  entire  tragedy  of  im- 
passioned love,  which  conflicts  with  the  dictates  of  morality  and 
convention,  and  sometimes  finds  its  bitter  end  in  suicide  or  a  double 
self-destruction.  Love  in  which  the  senses  play  too  prominent  a 
part  can  never  be  a  true  and  lasting  love.  For  this  reason,  first 
love  is  as  a  rule  very  transitory,  since  it  is  in  most  cases  no  more 
than  the  first  flare  of  passion.  *  *  *  Platonic  love  is  a  thing 
without  existence,  a  self-deception,  a  false  description  of  sexual  sen- 
sations. 

Bcbcl  remarks  that  the  number  of  suicides  among  women  of  the 
ages  of  sixteen  to  twenty-one  years  is  an  exceptionally  large  one, 
and  he  refers  this  chiefly  to  unsatisfied  sexual  impulse,  unfortunate 
love,  secret  pregnancy,  and  to  betrayal  by  men. 


78  THE  SEXUAL  LIFE  OF  WOMAN. 

MENARCHE  PR«COX  ET  TARDIVA. 
(Precocious  and  Retarded  Menstrual  Activity.') 

By  the  term  precocious  menarche  we  understand  the  pathological 
state  in  which  a  typical,  four-weekly,  sanguineous  discharge  from 
the  female  genital  organs  sets  in  at  an  abnormally  early  age,  and  is 
to  be  regarded  as  a  symptom  of  a  premature  sexual  development. 
Very  commonly  such  children  with  precocious  menstruation  and 
premature  sexual  development,  exhibit  a  comparatively  high  body- 
weight,  great  development  of  fat,  early  dentition;  they  look  older 
than  their  years ;  and  they  have  genital  organs  that  also  develop 
very  early,  with  hair  on  the  pubes  and  in  the  axillae;  the  labia 
majora  and  the  breasts  resemble  those  of  full-grown  women,  and 
the  pelvis  also  has  the  adult  form.  Commonly  also  the  sexual  im- 
pulse develops  early,  whilst,  in  other  respects,  the  intellectual  de- 
velopment lags  behind  the  physical.  It  is  most  probably  a  primary 
hyperplasia  of  the  ovaries  that  gives  rise  to  precocious  menstruation, 
the  ovarian  follicles  ripening  earlier  than  usual.  Frequently  other 
pathological  processes  are  associated  with  this  early  sexual  develop- 
ment, such  as  general  lipomatosis,  rachitis,  and  new  growths  of  the 
ovaries.  In  several  cases  of  this  nature,  early  conception  has  also 
been  observed.  According  to  oriental  tradition,  Khadijah  was  mar- 
ried at  the  age  of  five  years  to  the  prophet  Mohammed,  who  co- 
habited with  her  three  years  later. 

Even  if  we  except  those  cases  in  which  in  earliest  infancy  there 
is  a  sanguineous  discharge  from  the  vagina  which  remains,  how- 
ever, an  isolated  occurrence,  or  if  repeated  is  repeated  a  few  times 
only  and  at  quite  unequal  intervals  (cases  in  which  the  bleeding  can- 
not be  regarded  as  menstrual  —  such,  for  instance  as  were  reported 
by  Eross  of  six  new-born  female  infants  in  whom  a  sanguineous 
discharge  from  the  vagina  appeared  three  or  four  days  after  birth 
and  lasted  two  to  five  days,  the  infants  not  remaining  subsequently 
under  observation), —  numerous  well-authenticated  cases  yet  remain 
in  which  menstrual  haemorrhage  was  observed  before  the  end  of 
the  first  year  of  life.  One  case,  even,  is  recorded  by  Bernard  in 
which  from  the  time  of  birth  to  the  twelfth  year  menstruation  with 
molimina  occurred  every  month,  lasting  two  days;  from  the  twelfth 
to  the  fourteenth  year  menstruation  ceased,  recurring  subsequently 
at  irregular  intervals. 

In  the  recorded  cases  of  such  precocious  menstruation  the  men- 
struation recurred  as  a  rule  at  regular  intervals  of  four  weeks ;  only 
in  quite  exceptional  cases  were  the  intervals  three  to  five  months. 

Some  of  the  most  striking  and  well-authenticated  cases  of  pre- 
cocious menstruation  recorded  in  the  recent  literature  of  the  subject 
are  appended. 


THE  SEXUAL  EPOCH  OF  THE  MENARCHE.  79 

Observed  by  Combys:  A  girl  aged  6  years  and  2  months  had 
the  appearance  of  a  girl  aged  14  or  15;  she  was  a  brunette,  3'  io|" 
in  height,  with  full,  firm,  rounded  breasts,  girth  of  chest  28^",  mons 
Veneris  covered  with  hair,  uterus  normal  on  rectal  examination, 
hymen  intact ;  menstruation  had  occurred  regularly  since  the  second 
year  of  life.  Mother  and  five  sisters  began  to  menstruate  between 
the  ages  of  twelve  and  fourteen.  General  condition  good. 

Case  recorded  by  Diamant:  A  girl  aged  6  years,  weight  75 
pounds,  thighs,  buttocks,  and  breasts  developed  like  those  of  a  sex- 
ually mature  woman,  axillae  and  mons  Veneris  covered  with  hair. 
Menstruation  began  at  the  age  of  2  and  recurred  regularly,  the  flow 
lasting  4  days. 

Case  recorded  by  Plyette:  A  girl  with  precocious  physical  de- 
velopment began  to  menstruate  in  the  fourth  year  of  life;  menstrua- 
tion continued  regularly  with  the  exception  of  two  monthly  periods, 
when  vicarious  epistaxis  occurred. 

From  the  collection  made  by  Gebhard  of  the  records  of  fifty-four 
cases  of  precocious  menstruation,  giving  the  first  appearance  and 
the  type  of  menstruation,  the  development  of  the  breasts,  the  other 
signs  of  premature  sexual  development,  and  any  complications  that 
may  have  been  observed,  we  extract  the  age  at  which  the  first  men- 
struation occurred.  This  was: 

In  a  new-born  infant  in I  case. 

At  the  age  of    2  weeks  in I  case. 

At  the  age  of    2  months  in  i  case. 

At  the  age  of    3  months  in  I  case. 

At  the  age  of    4  months  in  i  case. 

At  the  age  of    5  months  in  I  case. 

At  the  age  of    7  months  in  I  case. 

At  the  age  of    9  months  in   4  cases. 

At  the  age  of  10  months  in   2  cases. 

At  the  age  of  12  months  in 5  cases. 

At  the  age  of  15  months  in  I  case. 

At  the  age  of  16  months  in  I  case. 

At  the  age  of  18  months  in  2  cases. 

At  the  age  of  19  months  in  I  case. 

At  the  age  of  22  months  in  i  case. 

At  the  age  of    2  years  in 4  cases. 

At  the  age  of    2l/2  years  in  I  case. 

At  the  age  of    2  years  and  9  months  in I  case. 

At  the  age  of    3  years  in  6  cases. 

At  the  age  of    3^  years  in  I  case. 

At  the  age  of    4  years  in   4  cases. 

At  the  age  of    4  years   and   3    months    in I  case. 

At  the  age  of    5  years  in I  case. 

At  the  age  of    5^/2  years  in  i  case. 

At  the  age  of    6  years  in I  case. 

At  the  age  of    6l/2  years  in  I  case. 

At  the  age  of    7  years  in  3  cases. 

At  the  age  of    9  years  in  2  cases. 

At  the  age  of  I il/2  years  in I  case. 


8o  THE  SEXUAL  LIFE  OF  WOMAN. 

From  this  collection  of  Gebhard's  we  learn  that  in  one  case  men- 
struation already  existed  at  birth,  and  that  in  a  large  number  of 
cases  it  occurred  before  the  expiration  of  the  first  year.  In  many 
cases  the  development  of  the  breasts  preceded  the  appearance  of 
menstruation,  and  was  noticed  from  the  time  of  birth.  The  vulva 
also  early  exhibited  the  characteristics  seen  in  the  sexually  mature 
woman.  Further,  a  high  body-weight,  great  development  of  fat, 
and  early  dentition,  were  usually  seen  in  these  cases,  in  which,  how- 
ever, the  intellectual  development  was  not  in  correspondence  with 
that  of  the  body. 

In  several  of  these  cases  of  premature  puberty,  moreover,  sexual 
intercourse  and  even  parturition  occurred  at  a  very  early  age.  A 
girl  in  whom  menstruation  began  at  the  age  of  one  year,  gave  birth 
to  a  child  when  she  was  ten  years  old  (Montgomery}.  A  girl  who 
began  to  menstruate  at  the  age  of  nine  years,  became  pregnant 
very  shortly  afterward  (d'Outreport).  The  well-known  case  re- 
corded by  Holler,  in  which  at  birth  the  pubic  hair  was  already 
grown,  and  in  which  menstruation  began  at  the  age  of  two  years, 
was  also  one  of  very  early  pregnancy,  the  girl  giving  birth  to  a 
child  when  nine  years  old.  Another  girl  in  whom  at  birth  the  pubes 
were  already  covered  with  hair  began  to  menstruate  when  four 
years  old,  copulated  regularly  from  the  age  of  eight,  and  at  nine 
years  became  pregnant,  and  was  delivered  of  a  vesicular  mole  with 
an  embryo  (Molitor).  A  girl  began  to  menstruate  at  the  age  of  two, 
had  a  growth  of  hair  on  the  pubes  and  developed  mammae  at  the 
age  of  three,  and  became  pregnant  at  the  age  of  eight  (Cams). 
With  these  cases  must  be  classed  that  observed  by  Martin  in  America 
of  a  woman  who  was  a  grandmother  at  the  age  of  twenty-six. 
Lantier,  in  his  Travels  in  Greece,  speaks  of  a  mother  of  twenty-five 
with  a  daughter  of  thirteen. 

Observations  made  by  Kussmaul  and  by  Hofmeier  prove  that  in 
many  cases  changes  in  the  ovaries  form  the  probable  cause  of  pre- 
cocious menstruation  and  the  other  phenomena  of  premature  puberty. 
In  one  case  of  Hofmeier's,  for  instance,  of  a  girl  of  five  with  pre- 
cocious menstruation,  the  removal  of  a  rapidly  growing  ovarian 
tumor  was  followed  by  the  cessation  of  menstruation,  and  the  pubic 
hair,  which  had  been  shaved  off,  did  not  grow  again. 

Abnormally  early  puberty  related  to  the  early  practice  of  sexual 
intercourse  is  seen  in  many  prostitutes.  This  is  shown  by  the  fol- 
lowing figures  relating  to  150  prostitutes  in  Russia.  Sexual  inter- 
course began : 

Tn     I  prostitute  at  the  age  of 9  years. 

In     i  prostitute  at  the  age  of 10  years. 

In    4  prostitutes  at  the  age  of     12  years. 

In  12  prostitutes  at  the  age  of 13  years. 


THE  SEXUAL  EPOCH  OF  THE  MENARCHE.  81 

In  14  prostitutes  at  the  age  of 14  years. 

In  33  prostitutes  at  the  age  of 15  years. 

In  36  prostitutes  at  the  age  of : .  . . .     16  years. 

Thus,  among  the  150  prostitutes,  65  were  less  than  16  years  of  age. 

Parent-Duchatelet  found  among  3,517  prostitutes  under  official 
observation,  5.6  per  cent,  under  17  years  of  age.  There  were : 

2  prostitutes  under  10  years  of  age.  20  prostitutes  under  14  years  of  age. 

3  prostitutes  under  n  years  of  age.  51  prostitutes  under  15  years  of  age. 
3  prostitutes  under  12  years  of  age.  in  prostitutes  under  16  years  of  age. 
6  prostitutes  under  13  years  of  age. 

Martineau's  observations  also  showed  that  in  nearly  all  pros- 
titutes the  first  coitus  took  place  in  very  early  youth.  Of  607  prosti- 
tutes there  were  489  in  whom  defloration  had  occurred  between  the 
ages  of  5  and  20  years.  According  to  Grimmaldi  and  Gurrieri  de- 
floration usually  takes  place  in  prostitutes  before  they  attain  the  age 
of  10  years. 

Sometimes  we  find  increased  sexuality  in  early  life  as  a  pathologi- 
cal manifestation — psychopathia  sexualis.  Thus,  Esquirol  records 
the  case  of  a  little  girl  aged  four  years  who  undertook  improper 
manipulations  in  association  with  little  boys.  A  female  prisoner, 
Lombroso  writes,  had  at  the  age  of  six  years  practiced  mutual  mas- 
turbation with  her  brother  aged  seven,  and  at  the  age  of  eight  years 
underwent  defloration;  another  murderess,  while  still  a  schoolgirl, 
had  conducted  herself  after  the  manner  of  an  experienced  prostitute. 
Laurent  reports  the  case  of  a  girl  who  from  the  age  of  ten  was 
engaged  in  sexual  malpractices  with  her  brothers  and  sisters,  and 
finally  underwent  defloration  at  the  age  of  fifteen. 

In  many  cases  premature  sexual  development  is  manifested  by 
enlargement  of  the  breasts  and  growth  of  the  axillary  and  pubic 
hair,  and  yet  menstruation  fails  to  appear.  Thus,  Kussmaul  has  ob- 
served girls  who  while  yet  children  exhibited  all  the  external  char- 
acteristics of  sexually  mature  women,  but  who  had  not  yet  begun 
to  menstruate.  Ploss  has  published  a  photograph  showing  in  a 
girl  five  years  of  age  the  mons  Veneris  and  the  labia  majora  de- 
veloped like  those  of  a  full-grown  young  woman,  and  covered  with 
long  thick  hair;  in  this  case,  however,  not  only  had  menstruation 
not  yet  begun,  but  the  breasts  were  still  in  the  infantile  condition. 

The  opposite  state  to  menarche  prsecox  is  that  in  which  the  first 
appearance  of  menstruation  is  unduly  delayed ;  it  may  be  even  till 
after  the  age  of  twenty.  Such  a  postponement  of  the  menarche 
sometimes  occurs  in  girls  who  exhibit  at  this  period  of  life  an  ex- 
traordinarily great  general  fatty  development  of  the  body,  or  a  nota- 
bly severe  chlorotic  state  of  the  blood,  or  in  whom  during  the  years  of 

6 


82  THE  SEXUAL  LIFE  OF  WOMAN. 

development  some  sudden  and  extensive  change  in  the  mode  of 
life  has  occurred,  as  for  instance  when  the  girl's  place  of  residence 
has  been  removed  from  the  country  to  the  town,  or  when  she  has  had 
to  undertake  some  completely  new  kind  of  physical  or  mental  work. 
Raciborski  attributes  the  late  appearance  of  menstruation,  at  the 
ages  of  20,  22,  24,  or  26,  in  otherwise  healthy  girls,  to  an  "  apathy 
of  the  sexual  sense,"  a  phrase  which  does  not  convey  much  meaning. 

According  to  Marc  d'Espine,  puberty  occurs  early  in  girls  with 
dark  hair,  grey  eyes,  a  delicate  white  skin,  and  of  a  powerful  build ; 
late,  on  the  other  hand,  in  girls  with  chestnut  hair,  greenish  eyes, 
a  coarse  darkly-pigmented  skin,  and  of  a  delicate  weakly  build. 

The  genitals  of  girls  in  whom  the  first  appearance  of  menstrua- 
tion is  delayed,  frequently  exhibit  distinct  signs  of  the  backwardness 
of  the  reproductive  organs  in  their  development.  The  external  geni- 
tals, in  such  cases,  have  little  if  any  covering  of  hair,  and  are  flabby 
and  relaxed ;  the  body  and  the  fundus  of  the  uterus  are  shorter  and 
more  slender  than  usual,  the  uterus  as  a  whole  is  small  and  flaccid, 
sometimes  anteflexed;  the  vaginal  portion  of  the  cervix  is  small, 
often  almost  undeveloped,  its  anterior  lip  barely  projecting  above 
the  surface  of  the  vaginal  fornix ;  the  vagina  is  usually  short  and 
narrow.  The  ovaries  also  are  flaccid  and  inelastic,  and  occasionally 
are  remarkably  small.  The  breasts  are  small,  the  nipples  and  areolae 
undeveloped. 

In  other  cases,  notwithstanding  the  delay  in  the  appearance  of  the 
menarche,  the  genital  apparatus  is  developed  to  a  degree  quite  in 
correspondence  with  the  age,  but  some  pathological  condition  is 
present,  for  instance,  the  mucous  membrane  secretes  excessively, 
exhibits  a  catarrhal  tendency,  there  are  erosions  at  the  os  uteri,  etc. 

PATHOLOGY  OF  THE  MENARCHE. 

A  series  of  disturbances  of  function  and  pathological  changes  in 
the  organs  may  occur  at  the  time  of  the  menarche,  either  directly 
connected  with  the  genital  organs,  or  etiologically  dependent  upon 
the  changes  occurring  in  these  organs. 

The  commencement  of  menstruation,  as  we  have  already  men- 
tioned, may  itself  be  abnormal  in  character,  being  either  precocious 
(menarche  precox),  or  retarded  (menarche  tardiva).  But  even 
where  menstruation  begins  in  a  normal  manner,  the  period  of  the 
menarche  may  be  disturbed  by  a  great  number  of  pathological 
phenomena,  of  which  the  developmental  processes  occurring  in  the 
genital  organs  of  the  young  girl  must  be  regarded  as  the  cause. 
First  of  all,  the  menstrual  haemorrhage  itself  may  be  abnormal  in 
amount  and  duration.  Then,  again,  functional  disturbances  of  the 
most  various  character  may  occur:  especially  prominent  are,  dis- 


THE  SEXUAL  EPOCH  OF  THE  MENARCHE.  83 

turbances  of  haematopoiesis,  of  the  cardiac  functions,  and  of  the 
nervous  system,  and  constitutional  anomalies,  which  deserve  atten- 
tive consideration ;  in  addition  we  have  to  mention  disorders  of 
digestion  and  disorders  of  the  sense-organs,  among  which  latter 
certain  changes  in  the  skin  especially  deserve  attention. 

The  diseases  of  the  female  genital  organs  at  the  time  of  the 
menarche  are  very  various  in  nature.  Whereas  during  infancy  and 
early  childhood  the  uterus  and  its  annexa  are  in  a  state  of  com- 
plete quiescence,  so  that  nothing  occurs  in  them  to  attract  attention, 
at  the  approach  of  puberty  these  organs  emerge  from  obscurity,  and 
the  percentage  of  diseases  of  the  reproductive  organs  suddenly 
rises  to  a  great  height.  In  very  young  girls,  among  diseases  of  these 
organs,  we  observe  only  malformations,  malignant  tumors,  and 
gonorrhceal  infections,  and  these  pathological  states,  even,  are  quite 
rare;  but  at  puberty  all  this  is  altered,  and  we  have  to  do  with  dis- 
turbances of  the  menstrual  function  and  their  consequences,  and 
with  various  inflammatory  processes,  and  the  period  of  sexual  ma- 
turity offers  us  an  overplus  of  diseases  connected  with  the  reproduc- 
tive system,  justifying  the  epigram  of  the  French  gynecologist  who 
denned  a  sexually  mature  woman  as  "  un  uterus  servi  par  dcs  or- 
ganes."  20 

Anomalies  of  Menstruation. 

Not  infrequently,  though  the  catamenial  flow  has  appeared  at  the 
usual  age  and  has  for  a  time  been  regular,  pathological  disturbances 
of  this  function  ensue. 

Amenorrhcea  at  the  time  of  the  menarche  may  depend  on  com- 
plete aplasia  of  the  ovaries,  associated  with  a  rudimentary  and  im- 
perfect development  of  the  uterus.  In  such  girls,  the  development 
of  whose  reproductive  system  is  thus  imperfect,  the  continually  ex- 
pected menstrual  flow  fails  to  appear,  in  spite  of  the  fact  that  a 
recurrent  menstrual  discomfort,  evoked  by  the  congestion  of  the 
genital  organs,  recurs  at  intervals  of  four  weeks;  as,  for  instance, 
colicky  pains  in  the  abdomen,  irritable,  nervous  states,  and  mental 
disturbances.  Further,  amenorrhcea  may  be  due  to  one  of  the 
various  forms  of  atresia  of  the  genital  organs,  as  for  instance  to 
vaginal  or  hymeneal  atresia.  In  such  individuals  the  first  period 
passes  by  without  anything  to  attract  attention.  But  at  the  second 
period,  distress  will  usually  be  manifested ;  and  from  this  time  for- 
ward, painful  contractions  of  the  uterus  will  continue  to  occur  at 
four-weekly  intervals,  and  to  become  more  violent  as  period  succeeds 
period,  whilst  the  menstrual  discharge  is  wanting,  or,  to  speak 
strictly,  fails  to  find  an  outlet.  The  blood  collects  behind  the  seat 
of  atresia,  and  the  accumulation  gives  rise  to  pressure  symptoms 

20  "A  uterus  served  by  organs." 


84  THE  SEXUAL  LIFE  OF  WOMAN. 

affecting  the  bladder  and  the  rectum,  and  ultimately  also  the  sacral 
nerves. 

Menstruation,  after  its  first  appearance  in  normal  fashion,  may 
be  suppressed  in  young  girls  in  consequence  of  mental  impressions, 
such  as  sudden  fright ;  such  cases  are  observed  after  an  escape  from 
a  fire,  or  after  a  railway  accident.  Mental  stimuli  of  less  intensity 
but  longer  duration  have  a  similar  effect ;  sometimes  these  take  the 
form  of  auto-suggestion.  A  well-known  instance  of  the  latter 
phenomenon  is  furnished  by  the  case  of  a  girl  who,  in  consequence 
either  of  actual  intercourse  or  it  may  be  merely  of  too  intimate  an 
embrace  with  a  man,  fears  she  has  become  pregnant,  and  actually 
suffers  from  amenorrhoea  though  pregnancy  does  not  really  exist. 
I  saw  a  case  in  which  amenorrhoea  was  thus  produced  in  a  girl 
seventeen  years  of  age,  whose  ideas  on  the  process  of  sexual  inter- 
course were  still  far  from  clear.  She  had  permitted  a  young  man  to 
kiss  her  repeatedly  and  fervently,  and  to  clasp  her  in  a  close  em- 
brace. She  was  then  afraid  that  she  had  become  pregnant;  the 
catamenial  flow,  which  had  been  regular  since  she  was  fifteen  years 
old,  ceased  to  appear ;  and  it  was  not  until  at  length  I  was  consulted, 
was  able  to  assure  myself  that  the  girl  was  essentially  virgin,  and 
was,  therefore,  in  a  position  to  reassure  her  as  to  her  own  condition, 
that  menstruation  again  became  regular. 

Functional  amenorrhoea  may  also  occur  in  young  girls  in  conse- 
quence of  a  sudden  change  in  the  conditions  of  life,  a  removal  from 
town  to  country,  for  instance,  or  the  reverse,  travel  in  regions  where 
the  climatic  conditions  differ  widely  from  those  hitherto  experienced, 
or  a  change  from  an  active  to  a  sedentary  kind  of  occupation.  Of 
this  nature  is  the  following  case  observed  by  Winter:  Miss  Q., 
aged  20;  menstruation  began  at  the  age  of  13  and  was  regular  there- 
after; on  three  successive  occasions  amenorrhoea  occurred  during  a 
visit  to  Berlin,  in  one  case  lasting  3  months,  another  2  months, 
and  a  third  6  weeks,  whereas  when  at  home  menstruation  was  regular 
though  somewhat  scanty.  There  were  no  molimina.  Examination 
showed  the  wall  of  the  uterus  to  be  thin,  length  of  this  organ  7 
centimetres  (2$"),  both  ovaries  distinctly  palpable.  Such  a  form 
of  amenorrhoea  as  this,  commonly  disappears  when  the  girl  re- 
moves from  the  conditions  unfavorable  to  the  fulfilment  of  her 
sexual  functions  to  the  conditions  favorable  to  that  function. 

Not  infrequently  a  chill  is  in  young  girls  the  cause  of  suppression 
of  the  menstrual  flow  that  has  hitherto  been  quite  regular,  espe- 
cially effective  in  this  respect  being,  standing  in  cold  water,  getting 
the  feet  wet,  the  influence  of  rain  and  wind  at  the  menstrual  period 
on  the  insufficiently  clothed  lower  extremities,  and  vaginal  injec- 
tions with  water  at  too  low  a  temperature.  Such  cases  are  common 


THE  SEXUAL  EPOCH  OF  THE  MENARCHE.  85 

among  the  working  classes,  especially  in  washerwomen ;  but  they  are 
also  observed  among  the  well-to-do.  An  example  is  given  by 
Winter:  Miss  H.,  aged  19;  menstruation  began  at  the  age  of  13, 
regular,  at  intervals  of  4  weeks,  the  flow  lasting  2  to  3  days,  and  be- 
ing normal  in  amount.  Several  years  ago  the  patient  caught  a  severe 
cold  through  paddling  in  cold  water  during  the  period.  Suppression 
of  the  menses  resulted,  amenorrhoea  being  complete  for  a  year  and 
a  half.  Then  menstruation  recommenced,  but  was  irregular,  some- 
times anticipating,  sometimes  postponing  the  proper  period,  the 
interval  being  occasionally  as  long  as  four  months ;  when  it  occurred, 
the  flow  was  represented  by  a  drop  or  two  of  blood  only,  and  dys- 
menorrhoea  was  severe.  At  each  proper  period,  if  the  flow  failed  to 
appear,  severe  molimina  occurred  in  the  form  of  abdominal  cramps 
and  headache.  Examination  showed  the  uterus  to  be  normal  in 
shape,  4]^  centimetres  (I-24")  in  length,  with  a  very  thin  wall;  both 
ovaries  were  palpable,  but  smaller  than  normal. 

The  commonest  form  of  amenorrhoea  at  this  period  of  life  is, 
however,  the  constitutional  amenorrhoea  associated  with  chlorosis. 
In  chlorotic  subjects  we  have  to  do,  not  with  a  symptomatic  ab- 
sence of  the  menstrual  discharge,  but"  with  a  failure  of  the  ovarian 
function,  the  graafian  follicles  failing  to  ripen.  We  generally  find, 
according  to  Gebhard,  that  chlorotic  girls  begin  to  menstruate  at 
the  usual  age,  or  even  earlier.  Menstruation  recurs  once  or  twice 
at  irregular  intervals,  and  then  gives  place  to  complete  amenorrhoea, 
it  may  be  suddenly,  it  may  be  gradually,  the  flow  on  each  occasion 
being  scantier  than  before.  In  chlorotic  patients,  the  menstrual 
discharge,  when  present,  is  very  thin  and  watery,  and  often  con- 
tains a  large  admixture  of  mucus  derived  from  the  cervical  canal 
and  the  cavity  of  the  uterus.  The  amenorrhoea  may  be  of  short 
duration ;  or  it  may  last  for  a  long  time ;  so  that  it  is  not  until  after 
the  lapse  of  months  or  years,  and  as  a  rule  in  consequence  of  suit- 
able treatment,  that  menstruation  recurs,  being  henceforward  either 
normal  in  frequency  and  strength,  or  on  the  other  hand  permanently 
scanty  and  of  the  postponing  type.  The  associated  disorders  from 
which  the  patients  suffer  take  the  form  of  headache,  dizziness, 
syncope,  feelings  of  oppression,  disinclination  for  mental  and  physi- 
cal exertion,"  and  so  on.  Since  in  such  cases  the  ripening  of  the 
ovarian  follicles  also  fails  to  occur,  when  the  amenorrhoea  is  com- 
plete the  menstrual  molimina  are  generally  wanting  (Gebhard}. 

Stcphcnson  also  states  that  in  girls  who  have  been  chlorotic  for 
a  longer  or  a  shorter  time,  menstruation  frequently  begins  very 
early,  in  any  case  earlier  than  in  healthy  girls. 

Usually  in  these  cases  various  other  disorders  are  associated  with 
the  amenorrhoea,  such  as  colicky  pains  in  the  abdomen,  sensitiveness 


86  THE  SEXUAL  LIFE  OF  WOMAN. 

of  the  abdominal  wall  to  contact  or  pressure,  headaches,  attacks  of 
hemicrania,  general  mental  depression,  and  hysterical  manifestations. 

In  chlorotic  girls,  at  the  times  when  menstruation  is  due,  a  watery 
discharge  often  occurs,  sometimes  slightly  tinged  with  blood.  Dys- 
menorrhoea  may  also  occur  at  such  times. 

Attacks  of  menorrhagia  in  young  girls  are  usually  dependent  on 
disturbances  of  the  nervous  system.  Sometimes  such  an  attack 
occurs,  at  the  very  first  menstrual  period.  Occasionally  also 
menorrhagia  may  occur  in  association  with  chlorosis,  to  be  dis- 
tinguished according  to.  Virchoiv  from  a  rare  condition  named  by 
him  "  menorrhagic  chlorosis,"  characterized  by  excessive  menstru- 
ation of  an  anticipating  type.  The  bleeding  is  in  such  cases  seldom 
very  profuse,  however,  but  the  periods  are  very  long,  and  the  in- 
tervals exceedingly  short.  Castan  regards  such  profuse  menorrhagia 
and  metrorrhagia  occurring  in  young  chlorotic  girls,  especially  at 
the  commencement  of  puberty,  as  of  an  endoinfective  nature  de- 
pendent upon  auto-intoxication.  The  toxins  lead  to  inflammatory 
and  degenerative  changes  in  the  muscular  substance  of  the  uterus. 
According  to  Frankcl  in  these  cases  the  ovaries  are  usually  enlarged, 
seldom  smaller  than  normal.  • 

Fraclich  has  discussed  this  subject  exhaustively  in  his  monograph 
on  Menorrhagia  of  Young  Girls  and  Hypertrophy  of  the  Cervix 
Uteri.21  He  states  that  the  cases  of  menorrhagia  in  young  girls 
at  the  time  of  the  menarche  may  be  arranged  in  two  groups.  In 
one  of  these  the  patients  are  chlorotic,  and  menstruation  is  normal 
neither  in  amount  nor  in  duration,  but  it  is  the  long  continuance 
of  the  flow  rather  than  its  profuseness  that  gives  rise  to  danger; 
in  the  cases  belonging  to  the  other  group  the  patients  are  in  excel- 
lent health  at  the  commencement  of  puberty,  but  menstruation  soon 
takes  the  form  of  long-continued  and  profuse  menorrhagia.  Cases 
of  the  latter  kind  are  due  to  hypertrophy  of  the  cervix  uteri  and 
fungous  metritis.  Such  attacks  of  menorrhagia  in  young  girls  are 
seen  also  in  cases  of  infectious  disorders,  as  in  smallpox,  measles, 
scarlatina,  and  above  all,  influenza.  The  haemorrhage  often  begins 
in  the  first  days  of  the  infection,  and  even  during  the  period  .of  in- 
cubation, one  or  two  days  before  the  appearance  of  the  general 
symptoms.  If  the  patient  is  attacked  by  influenza  while  menstruat- 
ing, the  menstrual  flow  may  assume  the  character  of  a  true  men- 
orrhagia. More  often,  however,  in  such  cases,  we  have  to  do  with 
an  extra-menstrual  haemorrhage,  such  as  may  indeed  be  observed  in 
girls  who  have  not  yet  begun  to  menstruate. 

21  Mcnorrhage  des  Jeunes  Filles  et  Hypertrophic  du  Col  Uterin. 


THE  SEXUAL  EPOCH  OF  THE  MENARCHE.  87 

Inflammatory  Processes. 

Chronic  metro-endometritis,  both  corporal  and  cervical,  occurs 
occasionally  in  young  girls  during  the  years  of  development.  It 
is  especially  common  in  chlorotic  subjects;  and  next  to  these  in 
girls  who  are  careless  about  the  observance  of  hygienic  precautionary 
measures  during  the  menstruation.  Thus  it  may  result  from  physical 
exertion  among  the  working  classes;  and  from  dancing,  skating, 
riding,  or  mountaineering,  among  girls  belonging  to  the  well-to-do 
classes,  during  menstruation.  Again,  we  meet  with  it  in  girls  who 
work  very  hard  at  the  sewing-machine ;  and,  finally,  in  those  who 
have  long  practiced  masturbation.  Through  uncleanliness  at  the  time 
of  menstruation,  the  blood  with  which  chemise  and  drawers  are 
stained  and  the  pubic  hair  soiled,  undergoes  decomposition,  and 
this  may  lead  to  catarrhal  inflammation  of  the  vulva  and  vagina  and 
of  the  endometrium.  The  most  striking  symptom  in  persons  thus 
affected  is  the  discharge  of  mucus,  which  in  cervical  metro-en* 
dometritis  leads  to  a  very  moist  condition  of  the  external  genitals, 
and  leaves  greenish-yellow  spots  on  the  under-linen ;  in  corporal 
metro-endometritis  the  discharge  is  of  a  thinner  consistence,  milky 
in  appearance,  and  not  very  abundant.  As  a  result  of  the  endome- 
tritis,  the  patient  suffers  from  various  pains  in  the  body,  a  feeling 
of  fulness,  sacrache,  general  sense  of  fatigue,  and  diverse  nervous 
manifestations;  sometimes  also  from  dysmenorrhcea,  strangury,  or 
obstinate  constipation.  In  consequence  of  the  great  thickening  of 
the  mucous  membrane  that  often  occurs,  menstruation  becomes  very 
profuse  and  long-continued,  lasting  from  one  to  two  weeks. 

A  form  of  chronic  vulvitis,  sometimes,  though  indeed  quite  rarely, 
met  with  in  girls  at  this  time  of  life,  is  inflammation  of  the  external 
genitals  dependent  on  masturbation.  As  characteristic  signs  of  this 
we  may  observe  an  elongation  of  the  nymphae,  the  clitoris,  or  the 
praeputium  clitoridis,  and  at  the  same  time  on  the  inner  surface  of 
the  greatly  stretched  labiae  we  may  notice  a  great  increase  in  the 
sebaceous  glands,  so  that  the  yellowish  spots  formed  by  these  struct- 
ures may  be  seen  beneath  the  mucous  membrane  with  the  unassisted 
eye  —  the  mucous  surface,  indeed,  may  be  slightly  uneven  in  con- 
sequence of  their  enlargement,  so  that  they  resemble  small  retention- 
cysts.  The  mucous  membrane  of  the  vulva  between  the  margin  of 
the  hymen  and  the  nymphae  is  moreover,  according  to  Veit's  descrip- 
tion of  masturbatory  vulvitis,  often  beset  with  small  pointed  ex- 
crescences, the  soft  furrow  between  the  clitoris  and  the  external 
orifice  of  the  urethra  being  very  commonly  marked  by  swelling  of 
the  mucous  membrane  and  the  presence  of  these  little  outgrowths ; 
but  sometimes  also  the  parts  lying  to  either  side  of  the  urethral 
orifice  may  exhibit  similar  changes.  These  small  structures  differ 


88  THE  SEXUAL  LIFE  OF  WOMAN. 

entirely  from  pointed  condylomata  —  they  do  not  branch,  they  occur 
only  upon  the  vulval  surface  proper,  not  upon  the  parts  exhibiting 
the  characters  of  true  skin,  and  they  are  non-infecting.  More  par- 
ticularly, it  must  be  remembered,  we  find  these  changes  principally 
in  virgins  in  whom  on  account  of  obscure  symptoms  an  examina- 
tion of  the  genital  organs  has  been  undertaken,  and  who  suffer  in 
addition  from  nervous  and  hysterical  manifestations.  The  hymen, 
when  intact,  as  it  usually  is  in  these  cases,  furnishes  objective  evi- 
dence that  sexual  intercourse  is  not  the  cause  of  the  patient's  trouble, 
and  indeed  a  distinctly  ascertainable  cause  is  hard  to  find.  The 
patient  usually  exhibits  abnormal  sensitiveness  and  excessive 
prudery.  Veit  is  of  opinion  that  the  association  of  all  these  symptoms 
justifies  the  diagnosis  of  masturbation  as  the  exciting  cause  of  the 
chronic  vulvitis ;  in  such  cases  we  may  at  one  time  find  the  mucous 
membrane  pale,  but  at  a  later  examination  fiery  red,  and  we  often 
see  a  clear,  transparent  secretion  exuding  from  the  ducts  of  Bartho- 
lin's  glands. 

In  consequence  of  long-continued  masturbation,  other  patholog- 
ical changes  may  take  place  in  the  female  genital  organs,  such  as 
hypertrophy  of  the  nymphse,  proliferation  or  glandular  hyper- 
trophy of  the  uterine  mucous  membrane,  ovarian  irritation,  pains 
in  the  ovarian  region  which,  in  severe  attacks,  may  radiate  to  the 
thighs.  These  pains  become  more  severe  at  the  menstrual  period, 
especially  at  the  beginning  of  that  period;  and  are  sometimes  also 
especially  troublesome  in  the  middle  of  the  intermenstrual  interval, 
in  this  case  usually  as  a  result  of  great  bodily  exertion. 

These  morbid  processes  in  the  genital  organs  of  young  girls 
have  long  attracted  the  attention  of  physicians,  and  it  is  more  than 
sixty  years  since  Bennet  described  the  "  virginal  metritis  "  observed 
by  him  in  twenty-three  virgins.  Bonion  published  in  1887  a  mono- 
graph on  this  condition.  Gallard  assigns  masturbation  as  its 
principal  cause. 

Retroflexion  of  the  uterus  is  also  sometimes  observed  in  virgins, 
induced  by  the  bad  habits  which  are  so  common  in  young  girls  of 
retaining  the  urine  for  excessively  long  periods  and  of  neglecting 
constipation.  The  prolonged  distension  of  the  bladder  leads  to  a 
daily,  long-continued  stretching  of  the  ligamentous  apparatus  of 
the  uterus ;  the  full  bladder  presses  the  uterus  backwards,  and  after 
the  viscus  has  been  emptied,  the  flaccid  ligaments  are  no  longer 
able  to  restore  the  uterus  to  its  normal  position  of  anteflexion. 
The  organ  is  left  wath  its  fundus  directed  backwards,  and  the  intra- 
abdominal  pressure  keeps  it  permanently  in  this  position;  at  the 
same  time,  an  accumulation  of  faeces  in  the  rectum,  by  pressing 
the  cervix  forward,  favors  this  displacement  of  the  uterus.  More- 
over, when  the  uterine  tissues  are  flaccid  through  malnutrition  in 


THE  SEXUAL  EPOCH  OF  THE  MENARCHE.  89 

chlorotic  or  anaemic    subjects,    the    organ    yields    more  readily  to 
mechanical  influences  than  it  would  if  its  muscular  tone  was  healthy. 

Disorders  of  H&matopoicsis. 

Chlorosis  is  in  general  rightly  regarded  as  a  disease* of  the  period 
of  puberty  etiologically  dependent  on  the  processes  that  at  this 
time  of  life  occur  in  the  genital  organs.  Its  appearance  gen- 
erally coincides  with  the  menarche,  occuring  at  the  age  of  14 
to  1 6,  or  even  later,  at  the  age  of  19  to  21.  As  regards  the 
composition  of  the  blood  in  chlorosis,  investigations  have  shown 
that  its  haemoglobin-richness  is  always  diminished ;  its  specific 
gravity  is  proportionately  lessened,  but  the  specific  gravity  of  the 
serum  is  normal.  The  erythrocytes  are  normal  in  number,  or 
only  slightly  ^diminished ;  their  shape  is  sometimes  normal,  some- 
times, however,  poikilocytosis  is  present.  The  leucocytes  are  gen- 
erally normal  both  as  regards  number  and  form;  myelocytes  (Mark- 
zellen)  are  -also  described  as  present  in  the  blood  of  chlorotic 
patients  (Neusser,  Hammer schlag,  Gilbert,  Weil)  ;  the  blood-plates 
are  normal  in  number,  the  alkalinity  of  the  blood  also  normal,  the 
isotonicity  of  the  erythrocytes  rather  low. 

The  relation  of  chlorosis  to  the  menarche  is  variously  explained. 
Kahane,  in  his  elaborate  monograph  on  chlorosis,  regards  it  as  an 
independent  disease  belonging  to  the  group  of  "  disorders  of  vegeta- 
tion "  (Knndrat),  one  which  "according  to  its  essential  nature  is 
an  expression  of  the  disharmony  that  obtains  between  the  congeni- 
tally  inefficient  haematopoietic  apparatus  and  the  demands  made 
upon  the  feminine  organism  by  the  processes  of  puberty." 

An  insufficiency  of  the  haematopoietic  organs  as  regards  their 
functional  capacity  is  believed  by  Kahane  to  be  in  the  case  of  women 
so  far  physiological  inasmuch  as  their  blood  is  inferior  to  that  of 
men  in  haemoglobin-richness  and  corpuscular  richness  to  the  extent 
of  about  10  per  cent.  In  this  way  the  predisposition  of  the  female 
sex  to  chlorosis  may  perhaps  be  explained.  A  further  fact  which 
must  be  taken  into  consideration  is  the  difference  between  the  de- 
velopment undergone  by  the  respective  sexes  at  puberty.  In  the 
female  sex,  this  development  is  quickly  completed,  and  has  the 
characteristics  of  a  revolution ;  but  in  the  male,  the  development  is 
a  more  gradual  one,  and  has  the  characteristics  of  an  evolution. 

F.  A.  Hoffmann  also  regards  chlorosis  as  associated  with  the 
development  of  the  uterus  and  the  establishment  of  menstruation. 
It  is  possible  that  these  processes  exercise  some  reflex  influence; 
but  we  must  also  remember  that  the  chemical  processes  involved 
in  the  growth  and  maturation  of  the  ovarian  follicles  are  still  in- 
sufficiently understood,  and  that  it  is  quite  possible  that  these  too 


90  THE  SEXUAL  LIFE  OF  WOMAN. 

may  have  powerful  and  unaccustomed  effects  on  the  organism  such 
as  may  well  disturb  metabolic  processes  of  a  somewhat  unstable 
character. 

Grawits,  who  regards  chlorosis  as  a  vasomotor  neurosis  in  which 
disturbances  arise  in  the  interchange  of  fluids  between  the  tissues 
and  the  vessels,  refers  the  appearance  of  chlorosis  at  puberty  to  the 
general  disposition  to  disorder  exhibited  at  this  age  by  the  vasomotor 
system. 

Other  authors  consider  chlorosis  to  be  an  ovarian  auto-intoxica- 
tion, believing  that  under  certain  conditions  the  ovaries  give  off 
into  the  organism  certain  poisons ;  or,  on  the  other  hand,  supposing 
that  a  certain  antitoxic  function,  normally  possessed  by  the  ovary, 
fails.  Von  Noorden,  for  instance,  regards  chlorosis  as  a  disorder 
of  blood  formation  referable  to  a  disturbance  of  the  internal  secre- 
tion of  the  ovary  during  the  developmental  period.  • 

Blondcl,  who  also  regards  .ovarian  auto-intoxication  as  causal, 
is  of  opinion  that  chlorosis  is  induced  by  products  of  decomposi- 
tion formed  in  the  organism  during  the  process  of  growth.  As  in 
childhood  the  thymus  gland,  so  later  in  life  the  ovary,  renders  these 
products  innocuous.  When  this  peculiar  functional  activity  of  the 
ovary  is  retarded  in  its  appearance,  the  intoxication  effected  by  the 
products  of  decomposition  formed  during  the  process  of  growth 
gives  rise  to  chlorosis. 

Meincrt,  in  an  interesting  manner,  brings  the  harmfulness  of 
wearing  a  corset  during  the  years  of  development  into  etiological 
relations  with  chlorosis.  In  the  transitional  period  between  child- 
hood and  the  age  of  puberty  the  wearing  of  the  corset  usually  begins. 
Now  Meinert  discovered  that  in  chlorosis,  as  a  result  of  wearing 
a  corset,  a  vertical  or  subvertical  position  of  the  stomach  ensues 
as  a  partial  manifestation  of  enteroptosis,  leading  to  tension  on  the 
abdominal  plexus  of  the  sympathetic,  which  in  turn  results  in  changes 
in  the  blood,  and  other  nervous  symptoms.  According  to  this  view, 
chlorosis  is  a  peculiar  general  neurosis  dependent  upon  an  artificially 
induced  gastroptosis ;  this  form  of  enteroptosis  being  due,  not  to 
relaxation  of  the  suspensory  ligaments  of  the  abdominal  viscera, 
but  to  pressure  exercised  by  adjacent  organs  in  consequence  of  a 
change  in  the  form  of  the  thorax,  which  has  been  permanently 
constricted  by  tight-lacing  (fijriertcr  Schnurthorax). 

Of  importance  is  the  fact  that  in  girls  suffering  from  chlorosis  a 
condition  of  hypoplasia  of  the  genital  organs  is  not  infrequently 
met  with.  It  would  seem,  not  only  that  imperfect  development  of 
the  female  genital  organs  may  be  a  cause  of  chlorotic  changes  in 
the  blood,  as  appears  possible  in  view  of  the  relations  between  the 
ovaries  and  the  haematopoietic  organs  through  the  intermediation 


THE  SEXUAL  EPOCH  OF  THE  MENARCHE.  91 

of  the  sympathetic  system;  but  also  that  genuine  chlorosis  and  the 
anomalies  of  the  genital  organs  met  with  in  this  disease,  may  per- 
haps be  common  manifestations  of  some  more  general  disturbance. 

According  to  Vircho^v,  two  distinct  forms  of  chlorosis  are  to  be 
recognized,  one  form  in  which  no  great  abnormalities  of  the  repro- 
ductive apparatus  exist,  and  another  form  in  which  imperfections 
in  the  development  of  the  central  portion  of  the  vascular  system 
are  associated  with  similar  imperfections  in  the  reproductive  ap- 
paratus. In  many  cases  of  chlorosis,  he  found  the  ovaries  small  and 
imperfectly  developed,  in  an  infantile  condition ;  in  other  cases, 
however,  they  were  three  times  the  normal  size;  the  development 
of  the  uterus  in  such  cases  usually  corresponds  with  that  of  the 
reproductive  glands.  With  regard  to  the  etiological  connection  be- 
tween chlorosis  and  developmental  disturbances,  Virchow  inclines 
to  the  view,  that  in  chlorosis  a  predisposition,  either  congenital  or 
else  acquired  in  early  youth,  must  be  assumed  to  exist,  but  that  this 
does  not  manifest  itself  by  the  production  of  actual  disorder  until 
the  arrival  of  puberty;  and  he  considers  it  likely  that  primary  de- 
ficiencies of  the  blood  and  the  vascular  apparatus  hinder  the  develop- 
ment of  the  reproductive  apparatus. 

Sticda  found  that  in  chlorotics  displacements  of  the  uterus  were 
common,  with  abnormal  narrowness  of  the  vagina,  absence  of  the 
pubic  hair,  imperfect  development  of  the  pelvis,  and  the  growth 
of  the  breasts  interfered  with  to  this  extent,  that  the  nipples  and 
areolse  were  abnormally  small.  He  classifies  these  manifestations 
as  disturbances  of  development  in  the  sense  that  they  are  among 
the  so-called  stigmata  of  degeneration.  If  in  chlorotics  the  breasts 
in  certain  cases  have  a  normally  full  and  rounded  appearance,  this 
appearance  is  sometimes  deceptive,  the  fulness  being  due,  not  to  a 
proper  growth  of  the  parenchymatous  mammary  tissue,  but  to  an 
excessive  deposit  of  fat.  Genuine  chlorosis,  therefore,  not  referable 
to  some  other  primary  disorder,  is  a  developmental  disorder,  in  the 
sense  in  which  various  other  stigmata  of  degeneration  met  with 
in  the  human  body  are  developmental  disorders,  and  is  indeed  fre- 
quently associated  with  other  stigmata  of  degeneration,  or  with  mal- 
formations clue  to  arrest  of  development,  as  for  instance,  an  in- 
fantile type  of  pelvis  or  of  genital  organs,  abnormalities  of  the 
cranial  bones,  vaulted  palate,  the  root  of  the  nose  broad  and  de- 
pressed, extreme  prognathism. 

Hcgar  also  maintains  the  view  that  chlorosis  is  in  most  cases  a 
developmental  disturbance,  the  origin  of  which  is  not  limited  to 
the  so-called  years  of  puberty;  it  often  arises  from  noxious  influ- 
ences which  are  either  strictly  inherited  or  began  to  operate  when 
the  infant  was  still  in  her  mother's  womb.  Frcenkel  is  inclined  to 


0,2  THE  SEXUAL  LIFE  OF  WOMAN. 

regard  a  primary  developmental  disorder  of  the  genital  organs  as 
the  cause  of  many  cases  of  chlorosis. 

Recently,  Breucr  and  Scilcr  have  undertaken  experiments  on 
bitches,  which  they  spayed  at  the  outset  of  puberty,  and  from 
the  results  of  these  experiments  it  seems  probable  that  a  disordered 
influence  exercised  by  the  ovaries  on  the  blood  plays  a  part,  at  least, 
in  the  pathological  mechanism  by  which  chlorosis  is  induced. 

The  intimate  relationship  believed  to  exist  between  chlorosis  and 
the  sexual  life  of  woman  finds  expression  in  the  opinion,  which 
dates  back  to  the  days  of  antiquity,  and  has  been  widely  held  even 
by  physicians,  that  the  disease  (hence  designated  morbus  virgineus 
or  febris  amatoria}  is  due  to  sexual  abstinence  in  individuals  with 
powerful  sexual  impulse,  and  that  for  this  reason  chlorosis  is  often 
cured  by  marriage.  This  result  of  marriage,  which,  though  ap- 
parent merely,  may  indeed  often  be  witnessed,  is  explained  by 
Kahane  on  the  ground,'  that  in  very  many  cases,  the  symptoms  of 
chlorosis  become  less  severe  after  the  first  five  years  have  elapsed 
since  the  commencement  of  puberty,  the  improvement  occurring  quite 
independently  of  the  marriage  or  continued  celibacy  of  the  sufferer. 
The  influence  of  marriage  in  curing  chlorosis  is  thus  apparent 
merely  to  this  extent,  that  a  very  common  age  for  marriage  in 
women  is  precisely  in  the  twentieth,  twenty-first,  or  twenty-second 
year,  when  five  years  have  passed  since  menstruation  began.  By 
this  time  the  organism  will  to  a  large  extent  have  become  accom- 
modated to  the  demands  made  upon  it  by  the  processes  of  puberty. 
Experience  also  shows  that  chlorotic  girls  sometimes  continue  to 
suffer  from  the  various  symptoms  of  chlorosis  even  after  they  have 
•become  wives,  and  that  chlorosis  is  not  infrequently  rendered  more 
severe  by  the  puerperium  —  but  in  a  wife  it  is  no  longer  customary 
to  describe  such  symptoms  by  the  name  of  chlorosis,  they  are  called 
anaemia,  hysteria,  nervousness,  etc.  Further,  in  order  to  give  the 
doctrine  of  morbus  virgineus  its  death-stroke,  Kahane  directs  at- 
tention to  the  fact  that  numerous  cases  of  chlorosis  are  met  with  in 
young  girls  who  are  far  from  practicing  sexual  abstinence,  espe- 
cially, for  instance,  amongst  the  lower  classes,  amongst  whom  it  is 
hardly  customary  to  wait  for  marriage  before  beginning  sexual  in- 
tercourse. The  connection  between  masturbation  and  chlorosis, 
which  has  also  been  widely  alleged  from  the  etiological  standpoint, 
is  moreover  one  that  cannot  be  admitted.  On  the  other  hand  it  is 
easy  to  understand  that  the  erotic  reveries  which  are  so  often  seen 
in  chlorotic  girls  are  very  likely  to  induce  the  habit  of  masturbation. 

In  young  girls  at  the  time  of  the  menarche,  especially  in  those 
who  suffer  from  amenorrhcea  or  from  irregular  menstruation,  the 
anaemic  form  of  obesity  not  infrequently  develops.  Such  patients 


THE  SEXUAL  EPOCH  OF  THE  MENARCHE.  93 

at  the  time  of  puberty  exhibit  signs  of  marked  anaemia  in  associa- 
tion with  a  notable  increase  in  fat.  The  skin  in  such  cases  is  always 
strikingly  pale  and  of  .a  whitish-yellow  color ;  in  bodies  which  are 
in  other  respects  beautiful  the  bust  may  have  the  appearance  of  a 
marble  statue.  Such  girls  are  strikingly  slout,  but  the  fatty  tissue 
is  flaccid,  soft,  and  spongy,  and  dependent  parts  readily  become 
cedematous ;  the  muscular  system  is  generally  feeble. 

What  especially  characterises  this  anaemic  form  of  lipomatosis  in 
young  girls  is,  that,  even  in  mild  forms  of  the  affection,  cardiac 
symptoms  are  apt  to  become  prominent.  Frequent  and  violent  pal- 
pitation will  occur  even  in  the  absence  of  any  severe  exertion  or 
especial  excitement,  often  also  we  see  shortness  of  breath,  pre- 
cordial  pain,  anxiety,  respiratory  distress,  and  sensations  of  chilli- 
ness and  fatigue. 

The  principal  cause  of  the  obesity  in  these  cases  is  to  be  found  in 
the  anaemia,  inasmuch  as  the  diminution  in  the  number  of  the  eryth- 
rocytes  is  a  diminution  in  the  number  of  the  oxygen-carriers,  and  this 
entails  defective  and  insufficient  oxidation.  The  deficiency  in  the 
albuminous  constituents  of  the  body  also  gives  rise  to  a  rapid  and 
extensive  deposit  of  fat,  the  power  for  the  combustion  of  the  fats 
absorbed  from  the  food  being  insufficient.  An  auxiliary  factor  in 
producing  obesity  in  such  anaemic  girls  is  their  disinclination  to 
physical  exercise,  dependent  on  the  speedy  onset  of  sensations  of 
fatigue.  The  long-continued  repose  of  the  muscles,  and  the  re- 
maining almost  continuously  in  close  rooms  insufficiently  supplied 
with  oxygen,  also  result  in  the  withdrawal  from  the  blood  of  the 
circulating  fat  and  its  deposit  as  adipose  tissue. 

Albuminuria  at  the  time  of  the  menarche  is  a  disease  of  develop- 
ment which  is  not  infrequently  met  with  in  chlorotic  girls,  as  in 
adolescent  boys.  On  examination  of  the  urine  in  such  young  girls 
we  detect  the  presence  of  a  variable  quantity  of  albumin,  which  is 
present  especially  after  severe  physical  exertion,  mental  application, 
or  emotional  excitement,  whilst  the  urine  secreted  at  night  is  usually 
free  from  albumin.  The  skin  is  pale,  the  accessible  mucous  surfaces 
are  comparatively  colorless,  the  face  is  puffy,  the  eyelids  are 
oedematous ;  the  patients  suffer  from  various  nervous  troubles,  espe- 
cially headache  and  dizziness,  and  they  are  also  liable  to  dyspeptic 
disorders. 

The  cause  of  this  albuminuria  of  puberty  is  according  to  von 
Leube  in  part  disordered  haematopoiesis,  in  part  a  slight  degree  of 
cardiac  insufficiency  with  a  tendency  to  stasis.  At  the  time  when  the 
processes  of  development  and  the  growth  of  the  body  in  height  are 
most  active,  there  is  not  a  corresponding  increase  in  the  energy  of 
haematopoiesis,  and  the  heart  also  fails  to  keep  pace  with  the  growth 


94 


THE  SEXUAL  LIFE  OF  WOMAN. 


of  the  body  and  to  meet  the  demands  thus  made  upon  it  by  vigorous 
growth  and  increased  energy.  In  general  the  capacity  of  the  heart 
in  such  individuals  is  indeed  sufficient  to  n}aintain  the  circulation 
through  the  kidneys;  but  as  soon  as  the  functional  activity  of  the 
heart  is  more  strongly  taxed  and  the  energy  of  the  circulation  conse- 
quently declines,  albuminuria  occurs — and  occurs  all  the  more 
readily  in  consequence  of  the  fact  that,  the  haemoglobin-richness  of 
the  blood  having  been  lowered  by  the  customary  anaemia,  the  epithe- 
lium of  the  renal  glomeruli  is  badly  nourished  and  functionally  in- 
adequate. 

When  the  period  of  the  menarche  is  safely  passed,  when  the 
menses  recur  w;th  regularity,  and  the  chlorotic  manifestations  dis- 
appear, when  the  process  of  hsematopoiesis  has  improved  in  quality, 
and  the  growth  of  the  body  is  completed  —  when,  in  short,  the  func- 
tional equilibrium  of  all  the  vital  processes  becomes  re-established, 
the  albuminuria  of  puberty  ceases.  It  seems,  however,  that  those 
who  have  suffered  in  this  way  are  predisposed  to  a  return  of  the 
albuminuria  at  the  climacteric  period,  when  the  metabolic  balance 
is  once  more  disturbed. 

Cardiac  Disorders. 

The  commonest  cardiac  disorder  at  this  period  of  life  is  nervous 
palpitation,  occurring  in  young  girls  who  are  in  other  respects  in 
good  health,  being  free  from  anaemia  and  from  any  discoverable 
disease  of  the  heart  or  vessels.  That  this  disorder  is  dependent  on 
the  sexual  processes  is  indicated  by  the  fact  that  it  first  manifests 
itself  in  a  stormy  manner  some  time,  weeks  it  may  be  or  months,  be- 
fore the  first  appearance  of  menstruation ;  recurring  at  irregular 
intervals,  the  attacks  continue  till  after  the  first  menstruation,  and 
cease  soon  after  the  regular  return  of  the  period.  Objectively,  the 
palpitation  of  the  heart  manifests  itself  by  an  increase  in  the  fre- 
quency and  strength  of  the  cardiac  impulse,  and  increased  frequency 
and  tension  of  the  pulse ;  in  a  few  cases,  however,  it  is  perceived 
subjectively  only  by  the  patient,  as  a  distressing  sensation  of  ex- 
cessively frequent  and  powerful  cardiac  action.  In  the  former  group 
of  cases,  the  enhanced  activity  of  the  heart  is  perceptible,  not  only  by 
auscultation,  by  which  we  usually  find  the  heart-sounds  quite  pure, 
but  also  by  inspection,  which  shows  us  the  violent  agitation  of 
the  thoracic  wall  and  increased  pulsation  of  the  carotids.  On  per- 
cussion, no  change  is  found  in  the  area  of  cardiac  dulness.  The 
frequency  of  the  pulse  is  increased,  usually  reaching  120  to  140 
beats  per  minute;  it  is  full,  and  may  be  intermittent  or  irregular. 
In  those  cases  in  which  the  palpitation  of  the  heart  is  a  purely 
subjective  sensation,  we  find  no  increase  either  in  the  frequency  or 


THE  SEXUAL  EPOCH  OF  THE  MENARCHE.  95 

in  the  strength  of  the  pulse,  which  may  indeed  be  less  frequent 
than  normal.  With  the  palpitation  is  associated  a  sensation  of 
strong  pulsation  in  the  great  vessels  of  the  neck,  and  often  there 
is  pain  on  the  left  side  of  the  lower  part  of  the  chest,  with  a  sensa- 
tion of  shortness  of  breath,  respiratory  distress,  precordial  pain,  and 
a  feeling  of  pressure  upon  the  chest.  Respiration  is  shallow,  and 
abnormally  frequent.  The  attacks  of  palpitation  recur  daily  in  some 
patients,  in  others  at  intervals  of  several  days;  they  may  occur 
entirely  without  exciting  cause,  or  with  a  cause  so  trifling  that  it 
would  not  in  a  normal  subject  have  produced  any  nervous  excite- 
ment ;  the  duration  of  the  attacks  varies  from  a  few  minutes  to  sev- 
eral hours,  and  they  may  occur  either  by  day  or  by  night ;  in  the 
intervals  between  the  attacks  the  functions  of  the  heart  and  the 
arteries  are  conducted  in  a  normal  manner.  The  pulse-curves  I  have 
obtained  during  the  attacks  of  palpitation,  in  those  cases  in  which 
the  manifestations  were  objective  as  well  as  subjective,  exhibit  a 
high  pulse-wave,  the  upstroke  being  rapid  and  steep,  the  down- 
stroke  also  sudden  and  steep,  the  predicrotic  elevation  but  little 
marked,  the  dicrotic  elevation  often  very  distinct. 

Less  frequent  than  such  attacks  of  palpitation  recurring  at  ir- 
regular intervals  are  paroxysmal  attacks  of  tachycardia,  in  which 
the  frequency  of  the  heart  and  pulse  is  increased  to  an  enormous 
extent.  This  disorder  manifests  itself  a  little  time  before  the  first 
appearance  of  menstruation,  thenceforward  recurring  regularly 
every  three  or  four  weeks,  accompanying  menstruation,  or  occurring 
at  the  proper  menstrual  period  if  menstruation  is  in  abeyance ;  the 
attacks  last  several  days.  This  trouble  also  disappears  a  few  months 
after  the  establishment  of  menstruation. 

Associated  with  these  cardiac  troubles  are,  not  constantly  indeed, 
but  in  the  majority  of  cases,  disturbances  of  the  digestive  organs. 

From  the  heart-troubles  already  described,  another  group  of  cases 
must  be  distinguished,  which  are  also  observed  at  the  time  of  the 
menarche.  They  occur  in  girls  in  whom  the  first  appearance  of 
menstruation  is  strikingly  delayed,  not  having  yet  begun  at  the 
ages  of  18,  19,  or  20  years,  or  in  whom  considerable  irregularities 
have  occurred  in  connection  with  the  commencement  of  menstrua- 
tion. In  such  girls,  in  whom  menstruation  has  appeared  4ate  and 
been  irregular,  or  who  are  perhaps  entirely  amenorrhoeic,  cardiac 
troubles  may  be  so  pronounced  that  the  physician  may  be  led  to 
suspect  the  presence  of  organic  disease  of  the  heart.  The  most 
prominent  symptom  is  frequent  'and  violent  palpitation,  with  strong 
pulsation  in  the  carotids,  respiratory  distress,  and  feeling  of  anxiety, 
on  continued  exertion  or  even  on  very  slight  occasion.  On  percus- 
sion, the  heart  is  not  found  to  be  enlarged ;  on  auscultation,  the  heart- 


96  THE  SEXUAL  LIFE  OF  WOMAN. 

sounds  are  found  to  be  very  loud,  often  with  a  systolic  murmur  in 
the  mitral  region,  whilst  over  the  lower  end  of  the  internal  jugular- 
vein,  the  humnrng-top  murmur  (bruit  dc  diable)  is  audible.  The 
pulse  is  increased  in  frequency,  at  times  arhythmical,  and  easily  com- 
pressible. The  sphygmographic  tracing  usually  shows  a  subdicrotic 
or  dicrotic  character.  The  upstroke  is  not  high ;  the  dovvnstroke 
descends  low,  almost  to  the  lowest  level  of  the  curve,  before  the 
enlarged  dicrotic  elevation  begins.  The  skin  is  always  strikingly 
pale,  pale  also  are  the  visible  mucous  surfaces,  the  hsemogiobin- 
richness  and  the  corpuscular  richness  of  the  blood  are  considerably 
diminished,  a  feeling  of  fatigue  and  various  other  nervous  mani- 
festations are  constantly  present  —  in  short,  in  all  cases  we  have  to 
do  with  the  well-known  chlorotic  disposition,  sometimes  in  associa- 
tion with  the  manifestations  of  the  anaemic  form  of  lipomatosis  uni- 
versalis.  In  several  such  cases,  skin  affections  were  also  present. 
Some  suffered  from  acne  vulgaris  of  the  face  with  the  usual 
comedones ;  others  perspired  profusely  from  the  palms  of  the  hands 
and  the  soles  of  the  feet ;  others  exhibited  a  bluish  coloration  of  the 
nose  and  the  ears. 

There  is  yet  a  third  form  of  heart  trouble,  much  rarer  indeed 
than  the  forms  already  described,  from  which  young  girls  some- 
times suffer  at  the  time  of  the  menarche.  It  occurs  in  girls  who 
just  before  the  first  appearance  of  menstruation  have  grown  very 
rapidly,  "  sliooting  up  to  a  great  height."  They  are  not  anaemic, 
nor  do  they  appear  "  nervous ;"  but  they  are  extremely  thin,  and 
they  have  grown  enormously  in  height  during  the  previous  year. 
These  individuals  also,  who  in  the  previous  course  of  their  life 
have  been  free  from  heart  trouble,  now  complain  of  cardiac  distress. 
As  in  the  cases  previously  described,  they  complain  of  severe  pal- 
pitation, a  feeling  of  fulness  in  the  chest,  shortness  of  breath  on 
exertion,  etc. ;  but  the  results  of  the  objective  examination  are  very 
different.  The  cardiac  dulness  is  increased  in  area,  especially  in 
vertical  extent,  the  apex-beat  may  be  normal  in  position  or  dis- 
placed outwards,  the  impulse  is  always  heaving,  abnormally  power- 
ful and  resistant,  the  heart-sounds,  especially  those  of  the  left  ven- 
tricle, are  louder  than  usual,  the  aortic  second  sound  accentuated, 
sometimes  ringing,  the  carotids  pulsate  visibly.  The  radial  pulse, 
the  tension  of  which  is  abnormally  high,  can  be  compressed  by  the 
finger  only  with  difficulty ;  sometimes  it  is  jerky  in  character.  The 
sphygmographic  tracing  shows  a  rapid  and  steep  upstroke ;  in  the 
downstroke,  the  predicrotic  elevation  is  much  larger  than  normal 
and  also  nearer  the  summit,  of  the  curve.  Thus  we  see  that  all  the 
signs  of  cardiac  hypertrophy  are  present,  hypertrophy,  that  is  to  say, 
of  the  left  venticle. 


THE  SEXUAL  EPOCH  OF  THE  MENARCHE.  97 

The  cases  of  this  nature  that  have  come  under  my  observation 
have  not  been  in  girls  of  the  working  classes,  but  among  the  well- 
to-do.  We  cannot  therefore  regard  them  as  due  to  overstrain  of  the 
heart  in  consequence  of  excessive  bodily  exertions,  comparable  to 
the  cases  met  with  in  young  recruits  after  long  marches  and  violent 
exercise.  We  must  rather  assume  that  the  development  of  the  fe- 
male genital  organs  has  evoked  a  storm  in  the  cardio-vascular  sys- 
tem, more  especially  that  in  some  way  an  increased  resistance  has 
been  offered  to  the  work  of  the  heart,  and  that  thus  the  hypertrophy 
has  been  brougfit  about ;  though  we  may  suppose  that  other  un- 
favorable influences  have  also  been  in  operation.  Such  an  influence, 
in  these  cases,  is  the  rapid  growth  of  the  body,  which  makes  enhanced 
demands  on  the  work  of  the  heart;  another  is  furnished  by  the  al- 
most universally  worn  unhygienic  article  of  clothing,  the  cuirass- 
like  corset,  which  offers  a  rigid  hindrance  to  the  rapid  growth  of  the 
female  body,  to  the  development  of  the  breasts,  the  thorax,  and  the 
upper  abdominal  organs,  and  which  fails  to  accommodate  itself  to 
the  changing  conditions  of  growth,  so  that  much  extra  work  is 
thrown  upon  the  heart.  In  such  young  girls  we  have  very  frequently 
found  tight  stays,  which  were  worn  unchanged  without  regard  to  the 
growth  of  the  body  in  length,  and  which,  by  pressure  on  the  epigas- 
tric region,  elevation  of  the  diaphragm,  and  limitation  of  the  respir- 
atory movements  of  the  thorax,  actually  offered  such  considerable 
resistances  to  the  driving  power  of  the  heart,  as  ultimately  to  lead 
to  hypertrophy  of  the  cardiac  muscle. 

Summing  up  our  observations,  we  find  that  at  the  time  of  the 
menarche  cardiac  disorders  occur  in  young  girls  which  may  be 
arranged  in  three  groups  of  cases : 

1.  Nervous  palpitation  and  paroxysmal  tachycardia  in  persons  in 
other  respects  in  good  health,  the  affection  appearing  shortly  before 
the  commencement  of  menstruation,  and  disappearing  soon  after  the 
flow  is  regularly  established. 

2.  Cardiac    disorders   occurring  in   young   girls   suffering    from 
chlorosis,  which  itself  results  from  the  processes  of  the  menarche. 

3.  Cardiac  hypertrophy  developing  at  the  time  of  the  menarche, 
and  dependent  on  the  circulatory  disturbances  associated  with  that 
process,  its  appearance  being  favored  also  by  rapid  growth  of  the 
girl  and  by  unsuitable  clothing  (tight  lacing). 

With  respect  to  the  activity  of  the  heart  and  the  circulation  of  the 
blood  at  the  time  of  the  menarche,  the  little-known  observations 
made  by  Beneke,  on  the  growth  of  the  heart  and  arteries  in  the 
various  stages  of  development,  deserve  especial  attention.  Accord- 
ing to  this  writer,  the  growth  of  the  heart  is  slow  until  the  age  of 
fifteen  years  is  attained,  but  becomes  accelerated  at  the  commence- 


98  THE  SEXUAL  LIFE  OF  WOMAN. 

ment  of  puberty.  During  this  time  of  puberty,  the  blood-pressure 
attains  its  highest  level,  being  comparatively  low  in  childhood  and 
later  in  life".  The  development  at  puberty  of  the  female  heart  is 
less  extensive  than  that  of  the  male  heart,  and  for  this  reason 
throughout  adult  life  the  capacity  of  a  woman's  heart  is  on  the 
average  25  to  30  cubic  centimeters  (1.5  to  1.8  cubic  inches)  less 
than  that  of  a  man.  In  women,  also,  the  great  arteries  are  on  the 
average  somewhat  smaller  than  in  men.  The  various  arteries  do 
not  develop  with  equal  rapidity  throughout  the  period  of  growth; 
after  puberty  the  common  carotid  grows  very  much  more  slowlv 
than  the  common  iliac  artery,  the  former  vessel  being  the  onlv 
large  trunk  which  has  already  nearly  reached  its  maximum  size  at 
puberty. 

The  comparatively  great  development  which  the  heart  undergoes 
at  the  time  of  puberty  is  a  phenomenon  so  important  alike  in  its 
physiological  and  its  pathological  relations  that  it  deserves  the  special 
designation  of  the  puberal  development  of  the  heart;  the  com- 
mencement and  the  completion  of  puberty  appear  beyond  question 
to  be  to  a  large  extent  dependent  upon  this  development  of  the 
heart  and  upon  the  simultaneous  rise  in  the  blood-pressure  of  the 
systemic  circulation  due  to  the  comparative  diminution  in  the 
calibre  of  the  arteries. 

In  the  literature  of  this  subject  of  cardiac  disorders  during  the 
menarche,  we  find  only  short  annotations  on  palpitation  of  the  heart 
in  young  adolescent  girls,  and  on  cardiac  manifestations  in  chlorotic 
subjects.  Further,  the  statistical  fact  that  valvular  lesions  of  the 
heart  are  commoner  in  women  than  in  men  is  by  many  authors  ex- 
plained on  the  ground  that  the  disturbances  of  the  time  of  puberty, 
which  certainly  occur  more  frequently  and  are  more  severe  in  the 
female  sex  than  in  the  male,  play  an  important  part  in  their  causa- 
tion. Changes  also  in  the  vessel,  such  as  cirsoid  aneurysm 
(angioma  arteriale  racemosum},  are  supposed  to  be  connected  with 
the  sexual  processes  of  this  period  of  life.  C.  Heine  maintains  that 
in  consequence  of  puberty  and  of  the  sexual  functions  that  become 
established  at  this  period,  a  teleangiectasis  will  not  infrequently  un- 
dergo transformation  into  a  cirsoid  aneurysm;  especially  in  cases 
in  which  menstruation  is  scanty  and  irregular,  angiectatic  tumors 
may  exhibit  a  vicarious  periodic  increase. 

Krieger  describes  nervous  palpitation  and  also  "  cramps  of  the 
heart  "  ^  as  occurring  in  girls  who  have  not  yet  begun  to  menstruate, 
in  the  form  of  prodromal  manifestations;  similar  attacks  may  occur 
also  at  every  menstrual  period  in  girls  in  whom  menstruation  is 

22  The  German  word  used  is  Herskrampf ';  in  the  first  line  of  the  paragraph 
it  is  used  in  the  plural,  and  in  inverted  commas.  Angina  pcctoris  proper, 
the  severe  and  often  fatal  disease  met  with  chiefly  in  elderly  men,  is  some- 


THE  SEXUAL  EPOCH  OF  THE  MENARCHE. 


99 


fully  established.  In  most  of  these  cases  the  pulse  is  increased  in 
the  patients  complain  of  a  sensation  of  anxiety,  and  speak  of  feeling 
the  heart  roll,  tremble,  or  flutter,  to  which  is  sometimes  superadded 
a  sensation  of  sudden  cessation  in  its  activity.  Not  infrequently 
there  is  a  blowing  adventitious  sound,  masking  or  accompanying 
the  heart-sounds ;  there  are  also  venous  murmurs,  especially  when 
the  heart-trouble  is  associated  with  anaemia  or  chlorosis.  Of  the 
cases  of  pseudo-angina  pectoris22  observed  by  Kriegcr,  the  attacks 
occurred  as  prodromal  manifestations  before  the  first  appearance  of 
menstruation  in  22  per  cent,  of  the  cases,  after  menstruation  was 
fully  established  in  78  per  cent,  of  the  cases ;  as  regards  the  relation 
of  the  attacks,  in  cases  of  the  latter  group,  to  the  menstrual  period, 
they  occurred  before  the  flow  in  33  per  cent.,  during  the  flow  in  67 
per  cent.;  menstruation  was  irregular  in  10  per  cent,  of  the  cases 
under  observation,  in  most  of  the  other  cases  menstruation  had 
been  irregular,  but  was  now  regular. 

Hcnnig  records  a  case  in  which  he  observed  as  a  prodromal 
symptom  before  the  establishment  of  menstruation  the  regular  re- 
currence of  congestion  of  the  pelvic  organs  associated  with  cardiac 
disorder. 

Diseases  of  the  Nervous  Syst&m. 

The  extensive  transformatory  processes  occurring  in  the  genital 
organs  of  young  girls  at  the  time  of  the  menarche,  and  the  power- 
ful impression  which  the  new  thoughts,  hopes,  and  fears  excited  at 
this  period  of  life  cannot  fail  to  exercise  on  the  nervous  and  emo- 
tional life,  will  enable  us  to  understand  how  it  is  that  the  appear- 
ance of  the  first  menstruation  may  give  rise,  especially  in  neurasthe- 
nic or  psychopathic  subjects,  to  manifold  nervous  disturbances  and 
also  to  disorders  of  the  mind. 

Amongst  the  severe  neuroses  and  psychoses  liable  to  occur  at  the 
menarche  in  those  suffering  from  congenital  nervous  weakness,  in 
those  the  conditions  of  whose  life  are  very  unfavorable,  and  in  those 
affected  by  some  sudden  disagreeable  and  powerful  influences,  we 
may  enumerate :  Hemicrania,  precordial  pain,  hysteria,  and  epi- 
lepsy ;  impulsive  manifestations,  such  as  bulimia,  longings  for 
various  unsuitable  things,  kleptomania,  and  pyromania ;  severe  feel- 
ings of  anxiety;  various  forms  of  psychoses. 

On  the  other  hand,  the  first  appearance  of  menstruation  has  some- 
times a  favorable  influence  in  girls  suffering  from  nervous  or 
mental  disorder.  This  is  seen,  for  example,  in  cases  of  chorea  in 

times  known  in  Germany  as  Herzkrampf,  but  the  established  and  distinctive 
German  name  for  the  affection  is  Stenokardia.  It  is  evident,  however,  that 
Krieger's  cases  are  not  cases  of  true  angina,  and  it  is  probable  that  they  would 
be  classed  by  English  physicians  under  the  heading  of  pseudo-angina  pectoris. 
—  TR. 


ioo  THE  SEXUAL  LIFE  OF  WOMAN. 

fully  developed,  rapidly  growing  girls  who  have  not  yet  begun  to 
menstruate;  in  such  subjects  the  chorea  sometimes  disappears  as 
soon  as  menstruation  is  regularly  established. 

Quite  frequently,  the  first  appearance  of  hemicrania  in  young 
girls  coincides  with  the  menarche.  According  to  Warner,  hemi- 
crania made  its  first  appearance : 

In  I  girl  of  3  to    4  years.  In  4  girls  of  10  to  n  years. 

In  2  girls  of  5  to    6  years.  In  2  girls  of  n  to  12  years. 

In  I  girl  of  6  to    7  years.  In  4  girls  of  12  to  13  years. 

In  5  girls  of  8  to    9  years.  In  15  girls  of  13  to  15  years. 

In  5  girls  of  9  to  10  years. 

Toothache,  according  to  Hollander',  in  the  early  days  of  puberty 
sometimes  exhibits  the  twenty-eight-day  type  of  menstruation.  The 
same  periodicity  has  been  recorded  in  cases  of  vicarious  bleeding 
from  the  gums  in  girls  suffering  from  disturbance  of  the  menstrual 
function. 

In  the  period  of  the  menarche  and  before  this  period,  chorea  minor 
occurs,  as  a  functional  disturbance  of  the  motor  region  of  the  nervous 
system,  and  especially  in  girls  is  it  associated  with  the  processes  of 
the  period  of  physical  development.  The  statistical  data  supplied 
by  a  number  of  authors,  Hughes,  Pye-Snrith,  Russ,  Sec,  and  Steiner, 
show  that  the  proportion  of  boys  to  girls  affected  with  chorea  minor 
is  I  to  2.8,  and  that  of  all  ages  49  per  cent,  of  the  cases  occurred 
at  the  ages  of  6  to  n  years,  29.8  per  cent,  at  the  ages  of  n  to  13 
years.  In  several  cases,  in  quite  young  girls  suffering  from  chorea, 
pathological  changes  were  found  in  the  genital  organs.  Thus,  in 
24  out  of  27  girls  from  the  age  of  9  to  15  years  affected  with  chorea, 
Marie  found  the  symptom-complex  designated  by  Charcot  as  ovarie. 
Ovarian  tenderness  was  manifested  on  palpation,  and  always  on 
that  side  on  which  the  chorea  had  first  manifested  itself.  Leonard 
found  in  a  girl  aged  eleven  suffering  from  chorea,  adhesion  of 
the  praeputium  clitoridis;  after  the  separation  of  the  prepuce,  the 
chorea  disappeared. 

As  in  respect  of  various  nervous  affections,  so  also  in  respect  of 
various  mental  abnormalities,  we  witness  at  the  time  of  the  menarche 
numerous  manifestations  confirming  the  statement  that,  "  no  spinal 
reflex  has  such  widely-opened  and  easily  accessible  paths  of  conduc- 
tion toward  the  organ  of  mind,  as  the  sexual  reflex."  "  The  men- 
strual proces,"  continues  Friedmann,  "  is  the  only  bodily  process 
in  relation  to  which  the  organ  of  mind  somewhat  readily  loses  the 
remarkable  stability  of  its  equilibrium." 

In  the  experience  of  all  alienists,  it  is,  speaking  generally,  the 
inherited  psychopathic  tendency  that  especially  manifests  itself  at 
the  time  of  puberty;  and  it  appears  that  this  predisposition,  the 
manifestations  of  which  the  resisting  powers  of  childhood  have 


THE  SEXUAL  EPOCH  OF  THE  MENARCHE.  101 

hitherto  been  competent  to  suppress,  undergoes  a  sudden  and  stormy 
development  in  consequence  of  the  action  of  the  menstrual  stimulus, 
leading  to  the  unexpected  appearance  of  mental  disorders.  The 
commonest  of  these  are  mania  and  melancholia  of  the  ordinary  type, 
the  prognosis  in  first  attacks  being  favorable;  next  in  frequency 
to  these  are  the  psychoses  characterized  by  fixed  ideas,  which  usually 
terminate  favorably  after  a  short  time ;  finally,  we  meet  with  the 
moral  psychoses  of  puberty,  and  the  form  of  melancholia  distin- 
guished by  Kahlbaum  as  Hebephrenie,zz  the  prognosis  of  which 
is  very  unfavorable,  for  it  speedily  terminates  in  dementia,  similarly 
to  the  dementia  of  puberty  described  by  Svetlin,  dependent  upon  or 
associated  with  premature  synostosis  of  the  cranial  bones.  Very 
often  we  witness  at  puberty  the  beginning  of  the  periodic  varieties 
of  mental  disorder,  which  develop  into  periodic  menstrual  psychoses, 
manifesting  themselves  regularly  at  the  recurrence  of  every  men- 
strual period. 

The  fact  that  hysteria  often  first  manifests  itself  at  the  time  of 
the  first  appearance  of  menstruation  was  noticed  already  by  Hip- 
pocrates,, who  indeed  believed  that  the  association  was  sufficiently 
explained  by  the  well-known  manifold  relations  between  this  nervous 
disease  and  disturbances  in  the  female  genital  organs.  The  first 
hysterical  attack  often  coincides  with  the  first  menstruation ;  or  the 
first  menstruation  may  lead  to  the  recrudescence  of  hysteria  which 
had  manifested  itself  previously,  but  had  passed  into  abeyance. 
We  have  to  deal  chiefly  with  the  minor  forms,  such  as  uncontrollable 
and  unconditioned  attacks  of  laughing  and  crying,  globus  hystencus, 
clavus  hystericus,  etc. ;  hysteria  major,  on  the  other  hand,  is  very 
seldom  observed  at  the  time  of  the  menarche.  As  regards  the  fre- 
quency of  hysteria  at  the  time  of  puberty,  we  append  certain  statisti- 
cal data. 

Landouzy  found: 

4  cases  of  hysteria  occurring  at  the  ages  of I  to  ro  years. 

45  cases  of  hysteria  occurring  at  the  ages  of 10  to  15  years. 

105  cases  of  hysteria  occurring  at  the  ages  of ~. 15  to  20  years. 

80  cases  of  hysteria  occurring  at  the  ages  of 20  to  25  years. 

After  the  age  of  twenty-five  is  attained,  the  frequency  of  hysteria 
declines  very  rapidly. 

According  to  Bernuts,  all  the  statistical  data  prove'  that  hysteria 
in  more  than  half  the  cases  first  manifests  itself  either  just  before 
or  simultaneously  with  the  commencement  of  menstruation.  It 
seems  also  that  at  the  time  of  puberty  amenorrhoeic  and  dysmenorr- 

23  Hebephrenie. —  There  is  no  current  Engli'sh  equivalent  of  this  word,  used 
by  Kahlbaum  to  denote  a  form  of  melancholia  occurring  at  puberty,  and 
terminating  in  dementia. —  TR. 


riiiz  i? 


IO2  THE  SEXUAL  LIFE  OF  WOMAN. 

hceic  manifestations  may  give  rise  to  the  development  of  hysteria. 
In  girls  at  this  time  of  life,  hysteria  seldom  takes  the  form  of  the 
great  hystero-epileptic  crisis,  manifesting  itself  rather  as  nervous  and 
moody  states  of  mind,  moral  changes,  weakness  of  will,  in  associa- 
tion with  various  forms  of  anaesthesia,  spasm,  and  paralysis. 

On  the  threshold  of  puberty  the  girl  with  a  hereditarily  neuro- 
pathic disposition  may  exhibit  a  tendency  to  epilepsy.  In  such  cases, 
as  Kou'alc.u>ski  writes,  the  patient  has  sudden  attacks  of  loss  of  con- 
sciousness, commonly  ushered  in  by  a  wild  scream;  during  the  at- 
tacks, tonic  and  clonic  muscular  spasms  occur,  the  patient  is  com- 
pletely insensible,  the  pupils  are  dilated  and  do  not  react  to  light, 
the  pulse- frequency  is  increased  —  in  short,  the  typical  phenomena 
of  an  epileptic  fit  are  exhibited.  The  loss  of  consciousness  lasts 
from  two  to  three  minutes ;  and  when  the  girl  recovers,  she  remem- 
bers nothing  of  what  has  occurred  during  the  fit.  Though  con- 
sciousness has  returned,  the  mind  is  still  at  first  somewhat  dis- 
ordered ;  but  this  disorder  soon  passes  off,  the  girl  becomes  calm,  and 
forgets  what  has  happened.  •  The  physician  is  summoned,  but  in 
ninety-nine  cases  out  of  a  hundred,  he  assures  the  relatives  that 
"  the  attaclj  is  nothing  of  any  consequence  —  a  simple  fainting-fit, 
the  result  of  menstruation  —  a  transient  trouble  merely."  A  second 
"  fainting-fit "  disturbs  the  calm  of  the  parents,  but  the  reiterated 
authoritative  assurance  of  the  physician  that  "  the  trouble  will  soon 
pass  away"  restores  their  confidence ;  and  they  gradually  become 
accustomed  to  the  "  fainting-fits  "  from  which  their  daughter  suf- 
fers at  each  successive  menstrual  period.  The  daughter  marries, 
and  gives  birth  to  neuropathic  and  psychopathic  children,  and  every 
one  wonders  what  can  be  the  cause  of  this  misfortune.  Hence  it  is 
necessary  to  pay  careful  attention  to  these  "  fainting-fits  during  men- 
struation." In  the  great  majority  of  cases  they  are  in  fact  epileptic 
seizures,  and  as  such  they  must  be  treated.  Binsu'anger  points  out 
that  in  such  cases,  in  which  epilepsy  first  appears  at  the  commence- 
ment of  menstruation,  the  attacks  may  continue  to  accompany  men- 
struation for  several  years  thenceforward.  Already  established 
epilepsy  is  said  by  some  authors,  Lawson  Tait,  Tissot,  and  Marottc, 
for  instance,  to  undergo  at  puberty  in  young  girls  an  increase  both 
in  the  severity  and  in  the  frequency  of  the  attack;  Esqnirol,  on  the 
contrary,  attributes  to  puberty  a  favorable  influence  on  the  course  of 
epilepsy,  a  view  held  already  by  Hippocrates. 

Not  infrequently,  attacks  of  precordial  pain  associated  with  tachy- 
cardia occur  during-  the  first  menstruation.  These  attacks  are 
usually  of  short  duration. 

Acromegaly,  a  disease  regarded  as  a  trophoneurosis,  also  requires 
mention  here,  this  disturbance  of  growth  being  considered  by  several 


?.V,L  rfi 


THE  SEXUAL  EPOCH  OF  THE  MENARCHE.  103 

authors,  and  especially  by  W.  Freund,  to  be  in  some  way  connected 
with  the  development  of  puberty;  the  tendency  to  acromegaly,  it  is 
suggested,  is  produced  by  the  remarkable  transmigration  that  occurs 
at  puberty  of  the  energy  of  growth  from  its  accustomed  paths  into 
new  channels.  The  relations  which  Neusser  has  shown  to  exist 
between  the  ovaries  on  the  one  hand  and  the  vegetative  nervous 
system  and  the  process  of  hsematopoiesis.on  the  other,  give  a  certain 
amount  of  support  to  this  hypothesis,  even  though  we  have  no  inti- 
mate knowledge  of  disturbances  occurring  in  the  reproductive  sys- 
tem during  the  period  of  development,  which  might  have  an  in- 
fluence in  the  causation  of  acromegaly. 

Of  old  and  of  recent  observations  on  the  psychoses  connected 
with  the  menarche,  there  is  no  lack.  From  the  time  of  Hippocrates 
down  to  the  present  day,  the  authorities  have  continued  to  report 
cases  in  which  the  commencement  of  menstruation  proved  the  ex- 
citing cause  of  the  appearance  of  psychoses.  Rousseau  writes  of  a 
girl  at  the  time  of  the  menarche,  who  before  the  first  appearance  of 
menstruation  suffered  from  attacks  of  melancholia  and  a  tendency 
to  pyromania,  and  under  the  influence  of  the  latter  tendency  she 
twice  committed  acts  of  incendiarism. 

According  to  Kirn,  the  psychoses  that  manifest  themselves  in  the 
first  period  of  the  commencement  of  menstruation,  sometimes  melan- 
cholia, sometimes  amentia  in  the  form  of  slight  and  transitory 
maniacal  derangement,  more  rarely  a  katatonic24  condition,  may 
precede  the  menarche,  or  may  accompany  or  follow  it. 

A  special  form  of  psychosis  is  associated  with  the  menarche  (von 
Krafft-Ebing,  Griesinger,  Friedmann,  Schonthal}.  The  influence 
exercised  by  puberty  in  this  direction  manifests  itself  in  various 
ways,  and  is  the  more  powerful  for  the  reason  that  several  factors 
are  in  operation,  each  of  which  exercises  an  individual  influence 
upon  the  type  of  the  psychical  affection ;  these  factors  are,  childhood, 
the  development  of  puberty,  and  the  periodicity  of  the  disturb: 
ance  exercised  by  the  menstrual  reflex.  The  last  named  of  these 
influences  is  the  most  potent.  It  manifests  itself  in  the  following 
manner :  Certain  psychoses  which  develop  before  the  commencement 
of  menstruation  or  during  the  suppression  of  the  flow,  undergo 
modification  when  menstruation  appears ;  further,  in  the  typical 
menstrual  psychoses  of  psychopathically  predisposed  girls,  the  at- 
tacks recur  either  at  the  beginning  of  each  period,  or,  when  the  flow 
is  in  abeyance,  at  the  dates  when  it  should  appear  —  the  menstrual 
stimulus  thus  being  the  exciting  cause  of  the  successive  attacks 
in  an  organ  of  mind  whose  resisting  powers  are  deficient ;  and,  finally 

24  Katatonia  (Katatonie")  is  a  term  used  in  Germany  to  denote  insanity 
associated  with  muscular  rigidity. —  TR. 


104  THE  SEXUAL  LIFE  OF  WOMAN. 

a  disturbance  in  the  development  of  menstruation  may  be,  not 
merely  the  exciting  cause,  but  the  efficient  cause  of  the  psychosis. 

In  cases  of  the  last  kind,  which  have  been  observed  by  Schonthal 
and  also  by  Fried  man  n,  who  has  described  them  very  fully  under 
the  name  of  primordial  menstrual  psychosis,  we  have  to  do  with 
young  girls  in  whom  the  appearance  of  menstruation  is  retarded, 
or  in  whom  the  flow  has  been  suppressed  very  soorr  after  its  com- 
mencement. The  girls  were  as  a  rule  hereditarily  well  endowed, 
and  the  psychosis  thus  appeared  without  warning,  like  a  storm  from 
a  clear  sky.  Exactly  periodical  in  form  and  character,  the  period 
of  recurrence  being  three  or  four  weeks,  this  phychosis  clearly 
showed  its  dependence  upon  menstruation ;  the  individual  attacks 
usually  lasted  a  few  days  only,  and  were  characterized  by  distinct 
mental  disorder,  in  the  form  either  of  maniacal  restlessness,  or  of 
dominant  depression ;  vasomotor  disturbances  were  very  prominent, 
with  disordered  pulse,  as  for  instance,  a  rapid  rise  in  the  pulse-wave 
just  before  the  onset  of  the  attack,  succeeded  during  the  attack  by 
a  correspondingly  rapid  decline. 

Friedmann  enumerates  a  number  of  the  peculiarities  that  char- 
acterize these  attacks.  The  general  course  of  the  malady  is  an 
exceptionally  stormy  one.  The  ultimate  cure  may  coincide  with 
the  definite  regularization  of  menstruation ;  or,  in  cases  in  which 
menstruation  is  restored  but  remains  inadequate,  the  course  of  the 
disorder  may  become  a  gentle  undulatory  one,  the  violent  stimulus 
of  total  suppression  being  replaced  by  a  more  moderate  stimulus  — 
here  also,  however,  a  cure  ultimately  follows  when  menstruation 
at  length  becomes  free  as  well  as  regular.  But  during  the  height 
of  the  malady  a  proper  development  of  menstruation  is  always 
wanting.  The  total  duration  of  the  malady  may  vary  from  as  little 
as  two  to  as  long  as  nine  months,  or  even  longer.  The  cure  is,  how- 
ever, ultimately  a  complete  one.  The  combination  of  a  disturbed  and 
delayed  development  of  menstruation  with  a  stormy  periodic  cycle 
of  attacks  of  mental  disorder,  and  the  ultimately  favorable  termina- 
tion, constitute  according  to  Fricdmann  the  peculiar  characteristics 
of  this  form  of  puberal  psychosis. 

Masturbation. 

Masturbation  is  sometimes  practised  in  very  early  childhood, 
being  then  commonly  due  to  local  irritation  of  some  kind,  as  for  in- 
stance when  threadworms  find  their  way  into  the  vagina.  Itching 
results,  leading  the  child  to  rub  the  genital  organs.  This  rubbing 
produces  a  pleasurable  sensation,  and  gives  rise  to  repeated  mastur- 
bation. But  in  adolescent  girls  at  the  time  of  the  menarche,  a  vague 
impulse  arises  to  handle  the  genital  organs,  depending  upon  cerebral 


THE  SEXUAL  EPOCH  OF  THE  MENARCHE.  105 

processes  which  are  themselves  the  result  of  sexual  sentiments,  of 
reading,  or  of  conversations  with  sexual  instructed  female  friends. 
This  vague  impulse  may  lead  to  masturbation,  and  will  do  so  earlier 
and  more  surely  if  the  girl  is  a  neuropsychopath  by  inheritance. 
The  local  influence  of  menstrual  congestion,  however,  also  plays  a 
part  in  provoking  the  impulse  toward  masturbation,  since  at  every 
period  a  hypersesthetic  state  recurs  in  the  genital  organs. 

Girls  thus  addicted  have  sometimes  a  very  striking  general  ap- 
pearance. They  are  pale,  with  a  weary  expression  of  countenance, 
their  eyes  are  dull-looking  and  darkly  ringed,  their  movements  are 
sluggish,  they  like  to  spend  a  long  time  in  bed  —  signs,  however, 
which  I  by  no  means  wish  to  adduce  as  characteristic  of  onanists. 

Temperament  and  mode  of  life  are  decisive  in  determining  the 
greater  or  less  frequency  of  the  habit  of  masturbation  in  young 
girls.  Girls  of  a  passionate  temperament,  those  also  who  from 
early  childhood  have  been  accustomed  to  mix  much  with  young  per- 
sons of  the  opposite  sex,  and  those,  finally,  in  whom  from  conversa- 
tion on  the  subject  with  female  friends  or  from  the  perusal  of  erotic 
literature,  sexual  enlightenment  has  occurred  at  an  early  age,  ex- 
perience the  awakening  of  the  sexual  impulse  earlier  and  with 
greater  force,  than  phlegmatic  girls,  than  those  who  have  grown 
up  apart  from  boys,  and  than  those  who  have  been  strictly  and  care- 
fully brought  up.  Masturbation  may  arise  either  instinctively  or 
from  instruction. 

In  young  girls  masturbation  is  usually  effected  by  friction  of  the 
clitoris;  less  often  by  intra-vaginal  manipulation,  since  this  is  liable 
to  lead  to  injury  to  the  hymen.  For  the  former  purpose  the  finger 
may  be  used ;  or  some  other  article,  such  as  a  knot  tied  in  the  night- 
gown, or  a  rounded  projection  on  some  article  of  furniture ;  in 
one  case  the  friction  was  effected  by  the  naked  heel.  If  two  female 
onanists  come  together,  they  practice  tribadism,  presently  to  be  de- 
scribed. Opportunity  for  this  practice  occurs  especially  in  institu- 
tions in  which  young  girls  occupy  a  common  dormitory,  and  sleep 
together  without  adult  supervision. 

An  experienced  physician,  Gutccit,  is  of  opinion  that  in  young 
girls  of  10  to  1 6  years  of  age  masturbation  is  on  the  whole  less  com- 
mon than  in  boys  of  the  same  age,  but  that  on  the  other  hand  from 
the  ages  of  18,  19,  and  20  onward,  "  sexual  self-gratification  is  al- 
most universally  practiced  by  women,  even  if  it  be  not  always  prac- 
ticed to  excess,"  an  opinion  which  cannot,  however,  be  regarded  as 
conclusive.  As  consequences  of  masturbation  in  the  female  sex, 
this  author  has  observed:  Fluor  albus,  menorrhagia,  enlargement 
and  prolapse  of  the  uterus,  pains  in  one  or  other  ovary,  hysterical 
paroxysms,  great  pallor. 


io6  THE  SEXUAL  LIFE  OF  WOMAN. 

L.  Lowenfeld  remarks  that  the  manifestations  of  the  sexual  im- 
pulse are  not  normally  present  in  the  days  of  childhood.  In  con- 
sequence of  pathological  conditions,  especially  of  such  as  effect  the 
genital  organs,  in  consequence  of  chance  impressions,  or  in  conse- 
quence of  a  bad  example,  sexual  passion  may  indeed  be  awakened 
in  children  in  its  fullest  intensity.  Normally,  however,  the  distinct 
manifestation  of  the  sexual  impulse  is  associated  with  a  certain  de- 
gree of  development,  of  ripeness,  of  the  reproductive  organs.  Phys- 
iologically, sexual  passion  is  entirely  wanting  in  young  girls  before 
the  age  of  puberty. 

As  regards  the  act  of  sexual  self-gratification,  this  author  dis- 
tinguishes two  forms  of  masturbation:  (a)  Peripheral-mechanical; 
(b)  mental  (psychical  onanism).  In  the  former  class  of  cases,  the 
sexual  orgasm  is  produced  solely  or  chiefly  by  mechanical  stimula- 
tion of  the  skin  or  mucous  membrane  of  the  genital  organs.  In 
the  female  sex,  in  addition  to  manual  stimulation,  an  extraordinary 
variety  of  hard  and  soft  articles  are  introduced  into  the  vagina  for 
this  purpose.  Many  females  effect  sexual  self-gratification  by 
rubbing  and  pressing  movements  of  the  thighs  one  against  the  other, 
in  which  the  clitoris  is  implicated.  In  psychical  onanism,  on  the 
contrary,  as  Lowenfeld  points  out,  the  orgasm  is  produced  solely 
by  central  stimulatory  representations,  without  the  assistance  of  any 
manipulation  of  the  genital  organs.  The  ideas  that  have  this  effect 
are  for  the  most  part  lascivious  trains  of  thought  or  the  recollection 
of  previous  sexual  experiences,  on  which  the  attention  is  concen- 
trated. If  we  wish  to  estimate  the  harmfulness  of  the  different 
forms  of  masturbation  as  regards  the  mind  and  the  nervous  system, 
psychical  onanism  must  incontestably  be  regarded  as  the  most 
deleterious. 

In  the  female  sex  onanism  is,  in  Lowenf eld's  opinion,  less  widely 
practiced  than  in  the  male;  none  the  less,  it  is  in  the  former  sex 
far  commoner  than  is  generally  believed,  a  fact  on  which  Eulenburg 
likewise  insists.  Frequently,  also,  in  females,  a  congenital  neuro- 
pathic tendency  plays  a  part  in  the  causation  of  masturbation,  in  so 
far  as  this  tendency  takes  the  form  of  premature  sexual  excitement 
or  of  excessive  intensity  of  the  sexual  impulse.  In  the  absence  of 
this  tendency,  masturbation  rarely  leads  to  the  production  of  well- 
marked  nervous  disturbances,  and  does  so  only  when  practiced  to 
very  great  excess.  Beard  reports  that  in  the  powerful  and  full- 
blooded  working-class  girls  of  the  Irish  race,  masturbation,  even 
when  practiced  for  many  years,  did  not  result  in  any  notable  dis- 
order to  health. 

As  regards  the  nature  of  the  nervous  manifestations  met  with 
in  women  as  a  result  of  masturbation,  there  develops,  according  to 


THE  SEXUAL  EPOCH  OF  THE  MENARCHE.  107 

Lbwenfeld,  in  one  group  of  the  cases,  the  sexual  form  of  myelas- 
thenia,  characterized  principally  by  sacrache  and  lumbago,  hyper- 
aesthesia  and  paraesthesia  in  the  domain  of  the  genital  organs 
(ovarie,25  pruritus  vulvae  et  vaginae,  etc.),  irritable  bladder,  coccy- 
godynia,  weakness  and  paraesthesia  of  the  legs  (feelings  of  fatigue 
and  chilliness),  finally,  the  onset  of  erotic  dreams.  In  many  cases, 
in  the  course  of  time,  to  these  symptoms  are  superadded  the  mani- 
festations of  cerebral  and  visceral  neurasthenia  (headache,  insomnia, 
nervous  dyspepsia,  palpitation),  so  that  the  clinical  picture  comes 
to  be  one  of  general  neurasthenia.  In  addition  to  the  neurasthenic 
troubles,  manifold  hysterical  manifestations  may  occur. 

Disorders  of  Digestion. 

Disorders  of  the  digestive  apparatus  are  quite  common  in  girls 
during  the  period  of  puberty,  and  usually  take  the  form  of  nervous 
dyspepsia.  Disturbances  of  sensibility  predominate,  with  a  sensa- 
tion of  pressure  after  meals,  sometimes  increasing  to  nausea,  retch- 
ing, and  vomiting,  as  manifestations  of  general  hyperaesthesia  of  the 
gastric  mucous  membrane,  loss  of  appetite,  a  pasty  or  acid  dis- 
agreeable taste,  sometimes  bulimia,  perverse  sensations  of  taste,  and 
pyrosis.  Especially  in  chlorotic  girls,  periodic  attacks  of  pain  occur, 
localized  in  the  epigastrium  and  its  neighbourhood,  and  exhibiting  no 
relation  to  the  ingestion  of  food.  The  free  hydrochloric  acid  varies 
in  amount,  being  now  normal,  now  diminished,  sometimes  also  in- 
creased. In  chlorotic  cases,  the  symptoms  of  round  ulcer  of  the 
stomach  are  sometimes  observed.  Intestinal  activity  is  usually  de- 
pressed, peristalsis  is  diminished,  so  that  more  or  less  obstinate 
constipation  is  one  of  the  most  frequent  symptoms. 

Hypertrophy  of  the  tonsils  at  the  time  of  puberty  is  in  some  way 
related  to  the  menstrual  processes,  whether  by  the  intermediation 
of  the  nervous  system  or  by  that  of  the  blood.  Eiscnhart  quotes 
observations  made  by  Chassaignac,  of  girls  eighteen  or  nineteen 
years  of  age  with  hypertrophy  of  the  tonsils,  associated  with  re- 
tarded puberty,  menstruation  having  begun  late  and  being  scanty,  and 
the  breasts  being  underdeveloped ;  in  one  young  girl  with  tonsillar 
hypertrophy,  one  of  the  breasts  had  failed  to  develop  properly,  but 
after  the  removal  of  the  tonsils  it  speedily  grew  to  the  normal  size. 

Diseases  of  the  Respiratory   Organs.26 

Not  uncommonly  at  this  period  of  life  the  growth  of  a  goitre  is 
observed.  The  influence  of  puberty  on  the  growth  of  the  thyroid 

25  A  term  introduced  by  Charcot.     See  page  97. 

26  The  author's  classification  is  adhered   to.     It  is  not  usual,   I  believe,  in 
Germany,  to  class  the  thyroid  body  among  the  organs  of  respiration.     But  the 
only  disease  mentioned  under  the  above  heading  is  goitre. —  TR. 


I08  THE  SEXUAL  LIFE  OF  WoMArf. 

body  has  indeed  been  asserted  by  several  authors;  and  Neudbrfer 
maintains  that  precisely  during  the  period  of  puberty  to  this  body 
must  be  assigned  an  important  regulatory  trophic  significance  for 
the  nourishment  and  growth  of  the  reproductive  organs.  Stein- 
berger  and  Sloan  record  the  observation  of  cases  occurring  in  young 
girls  in  whom,  menstruation  having  first  been  regular,  but  having 
been  suddenly  suppressed  in  consequence  of  external  noxious  in- 
fluences 'a  rapidly  growing  goitre  suddenly  appeared. 

P.  Midler  states  that  in  many  regions,  as  for  instance  in  Canton 
Berne  in  Switzerland,  where  the  school  children  exhibit  with  extraor- 
dinary frequency  a  hereditary  tendency  to  the  formation  of  goitre, 
during  the  years  of  childhood  these  growths  are  much  less  frequent 
in  girls  than  in  boys.  At  the  time  of  puberty,  however,  this  relation 
is  entirely  changed.  Whereas  in  boys  from  this  time  onward  no 
further  growth  of  the  thyroid  body  is  observed,  in  girls  at  puberty 
the  hypertrophy  greatly  increases,  so  that  very  large  goitres  are 
formed.  The  same  author  recurs  to  the  earlier  observations  of 
Heidenreich  and  Schonlcln,  as  well  as  to  those  of  Friedreich,  by 
which  this  influence  of  puberty  is  strikingly  manifested,  and  he  be- 
lieves it  to  be  established  by  experience  that  sexual  excitement  can 
produce  a  transient  swelling  of  the  thyroid  body.  He  alludes  also  to 
the  remarkable  fact  that  a  swelling  of  the  thyroid  body,  to  which  a 
number  of  animals  show  a  tendency, occurs  chiefly  at  the  time  of  heat 
or  rut;  this  is  especially  well  known  to  occur  in  the  case  of  stags. 
Similarly,  during  menstruation,  a  transient  swelling  of  the  thyroid 
body  can  sometimes  be  detected;  the  swelling  is  greater  if  the  men- 
strual discharge  fails  to  occur. 

Diseases  of  the  Organs  of  the  Senses. 

At  the  time  of  the  menarche  in  cases  in  which  there  is  retarda- 
tion or  some  other  disturbance  in  the  regular  appearance  of  men- 
struation, affections  of  the  eye  are  observed,  which  are  in  part 
functional,  dependent  on  reflex  influences  proceeding  directly  from 
the  genital  organs  without  organic  changes,  and  in  part  are  due  to 
circulatory  disturbances.  Mooren,  S.  Cohn,  and  Pozver  have  dis- 
cussed the  relations  between  the  uterus  and  the  eyes  in  general,  and 
also  in  this  especial  connection.  Of  ocular  troubles  during  the 
menarche,  iridochoroiditis,  haemorrhages  into  the  vitreous  body, 
long-continued  blindness,  and  pannous  keratitis,  are  mentioned, 
which  may  either  disappear  with  the  reestablishment  of  menstrua- 
tion (spontaneous  or  artificially  effected),  or  may  exhibit  in 
such  circumstances  a  notable  alleviation.  Chronic  inflammatory 
states  of  the  conjunctiva,  usually  of  an  eczematous  nature,  which 
frequently  occur  at  the  time  of  puberty,  often  exhibit  a  relation  to 
the  menstrual  process,  a  monthly  exacerbation  of  the  ocular  trouble 


THE  SEXUAL  EPOCH  OF  THE  MENARCHE.  109 

coinciding  with  disordered  menstruation,  and  cure  taking  place 
only  when  menstruation  has  become  perfectly  regular.  Vicarious 
haemorrhages  into  the  vitreous  body  also  occur,  associated  with 
disturbances  of,  menstruation,  the  relapses  ceasing  as  soon  as  men- 
struation becomes  regular ;  such  a  case  was  observed  by  Courserants 
in  a  girl  of  fourteen  years. 

Disturbances  of  hearing  have  been  observed  at  the  time  of  puberty 
in  young  girls  addicted  to  masturbation;  the  patients  complain  of 
subjective  noises,  rising  in  intensity  till  actual  hallucinations  may 
be  experienced.  Lichtenberg  reports  the  case  of  a  strong  girl 
eighteen  years  of  age,  in  whom  the  congestion  associated  with 
puberty  was  followed  by  atrophy  of  the  auditory  nerve.  The  same 
author,  also  AsJnvell,  Law,  Pnech,  Rossi,  Stepanoiv,  and  Gilles  de 
la  Tourctte,  have  published  cases  of  vicarious  menstrual  haemorrhage 
from  the  external  auditory  meatus,  occurring  in  girls  of  ages  varying 
from  14  to  1 6,  17,  20,  and  22  years.  Amongst  these  cases,  in  some 
the  auditory  organ  was  in  a  healthy  condition,  but  in  others  there 
was  associated  purulent  discharge ;  the  bleeding  took  place  from 
the  ears  at  the  menstrual  periods,  the  proper  menstrual  discharge 
being  absent  or  scanty ;  after  the  ear  trouble  was  cured,  menstrua- 
tion was  normal.  Of  200  cases  of  vicarious  menstruation,  there  were, 
according  to  Puech,  six  in  which  the  vicarious  bleeding  was  from 
the  ears. 

Disturbances  of  the  olfactory  sense,  taking  the  form,  sometimes 
of  diminished  acuteness  of  this  sense,  sometimes  of  increased  acute- 
ness,  and  sometimes  of  perversion,  also  anomalies  in  the  secretion  of 
the  nasal  mucous  membrane,  either  abnormal  dryness,  or  greatly 
increased  secretion  of  mucus,  come  under  observation  at  this  period 
of  life,  either  as  reflex  manifestations  through  the  intermediation 
of  vasomotor  nerves  at  the  time  of  the  first  appearance  of  menstrua- 
tion, or  in  consequence  of  chronic  nasal  catarrh,  which  may  be  con- 
nected with  masturbation.  In  cases  in  which  the  menarche  is  re- 
tarded, vicarious  epistaxis  may  also  occur,  the  bleeding  sometimes 
being  very  profuse,  in  one  case,  indeed,  reported  by  Fricke,  in  a 
girl  seventeen  years  of  age,  having  a  fatal  termination.  Accord- 
ing to  Mackenzie,  sexual  excitement  leads  to  swelling  of  the  nasal 
mucous  membrane,,  and  habitual  masturbation  to  chronic  nasal 
catarrh ;  the  same  author  asserts  that  during  menstruation,  swelling 
of  the  turbinate  bodies  may  always  be  observed,  and  that  in  this 
lies  the  explanation  of  the  fact  that  many  women  complain  of  a 
monthly  cold  in  the  head  as  an  accompaniment  of  menstruation. 

Diseases  of  the  skin  are  not  uncommon  in  young  girls  at  the  time 
of  the  menarche,  and  later  as  an  accompaniment  of  each  successive 
menstruation.  It  is  a  well-known  fact  that  at  puberty  girls  some- 
times lose  a  hitherto  beautiful  complexion,  and  suffer  from  various 


no  THE  SEXUAL  LIFE  OF  WOMAN. 

disfigurements  of  the  skin  of  the  face.  These  are  produced  espe- 
cially by  the  profuse  secretion  of  sweat,  and  by  the  excessive  secre- 
tion of  the  sebaceous  glands,  which  so  often  results  in  acne,  an  in- 
flammation of  these  glands.  Ecchymoses  also,  effusions  of  blood 
into  the  skin,  are  observed,  especially,  as  a  form  of  vicarious  men- 
struation, in  cases  in  which  menstruation  is  irregular.  When  actual 
bleeding  occurs  from  the  intact  skin,  the  blood  finds  its  way  out 
through  the  suderiferous  ducts  —  haematidrosis  occurs;  in  some 
cases,  however,  the  haemorrhage  takes  place  from  areas  of  skin 
altered  and  injured  by  disease,  from  wounds  or  other  injuries,  from 
ulcers,  or  from  excrescences.  Haemorrhage  into  the  skin  occurs 
also  in  the  so-called  stigmatization,  in  which  condition  also  an 
etiological  role  has  been  assigned  to  menstruation. 

In  the  skin,  remark  Spietschka  and  Griinfeld,  a  new  life  begins 
at  the  time  of  the  development  of  puberty,  and  it  is  this  which  first 
gives  to  human  beings  the  external  characteristics  of  sexual  maturity. 
In  certain  regions  which  have  hitherto  been  covered  only  by  fine 
downy  hairs,27  thick,  strong  hairs  develop,  and  at  the  same  time  the 
general  growth  of  hair  becomes  more  active.  These  regions  are, 
the  genital  region,  and  the  axillae.  This  increased  growth  of  hair 
is  accompanied  by  a  stronger  secretion  of  the  sebaceous  glands, 
which  very  often  is  in  excess  of  actual  requirements,  and  may  thus 
lead  to  cosmetic  disturbances  and  to  various  diseases  of  the  skin. 
Thus  arise  the  various  forms  of  seborrhoea.28  The  commonest  of 
these  is  the  formation  of  comedones,  which,  at  the  time  of  puberty, 
may  make  their  appearance  especially  on  the  nose,  the  forehead,  and 
below  the  corners  of  the  mouth,  but  also  on  other  parts  of  the  face 
or  on  the  back  and  the  breast;  in  those  regions,  that  is  to  say,  in 
which  the  sebaceous  glands  attain  a  considerable  size.  The  reten- 
tion of  the  sebum  may  give  rise  to  inflammation,  which  the  access 
of  micro-organisms  converts  into  suppuration.  Thus  arises  acne 
vulgaris.  In  another  form  of  seborrhoea,28  the  secretion  is  more 
fluid  in  consistence,  and  collects  on  the  surface  of  the  skin,  furnish- 
ing this  with  an  oily  covering  —  seborrhoea  oleosa.28  This  most 

27  In  Germany  the  term  Lanugo,  or   IVollhaar,  is  used  to  denote  the  rudi- 
mentary hairy  covering  of  the  body  throughout  life,  as  distinguished  from  the 
specialized  and  fully  developed  hairs  of  the  head,  beard,  axillae,    etc.     In  Eng- 
land the  use  of  the  term  lanugo  is  usually  restricted  to  denote  the  downy 
crop  of  hair  with  which  an  infant  is  covered  at  birth,  which  is  shed  in  a  few 
months    thereafter.     See    the    English    edition    of  Toldt's  Atlas    of    Human 
Anatomy,  Part  VI.,  Appendix,  note  503.— TR. 

28  It  will  be  noticed  that  the  author  uses  the  term  seborrhara   as  a  general 
term  for  diseases  of  the  sebaceous  glands,  including  acne.     In  England  acne, 
and  its  preliminary  stage,  the  formation  of  comedones,  are  separately  con- 
sidered, the  signification  of  the  term  seborrhoea  being  limited  to  denote  cases 
in  which  the  secretion  of  the  glands  forms  an  oily,  waxy,  or  scaly  accumula- 
tion on  the  surface.     Seborrhoea   oleosa  is  defined  by  Crocker  as  that  form 
of  the  affection  in  which  the  olein  is  in  excess. —  TR. 


THE  SEXUAL  EPOCH  OF  THE  MENARCHE.  in 

i 

commonly  occurs  on  the  face ;  if  the  fatty  layer  is  removed,  the 
skin  remains  dry  for  a  brief  period  only,  and  soon  becomes  greasy 
and  shiny  once  more.  Dust  readily  adheres  to  the  greasy  surface, 
and  this  gives  the  face  a  dirty  appearance.  Seborrhcea  faciei  is 
readily  converted  into  eczema. 

With  the  puberal  development  of  the  external  genital  organs  is 
associated  an  increase  in  the  sebaceous  secretion  of  these  regions. 
On  the  clitoris  and  its  prepuce,  and  on  the  folds  and  in  the  furrows 
of  the  vulva,  in  consequence  of  insufficient  cleanliness,  an  accumu- 
lation of  sebum  and  cast-off  epidermic  scales  readily  occurs ;  such 
an  accumulation  may  become  rancid,  may  irritate  the  skin,  and 
may  thus  give  rise  to  erosions  and  to  purulent  secretion. 

In  chlorotic  girls  at  the  time  of  puberty,  on  account  of  the  anaemic 
condition  of  the  blood,  eczema  is  not  uncommon,  especially  on  the 
hands  and  the  face.  On  the  face,  or  on  the  forehead,  red  papules 
appear  on  circumscribed  areas,  and  become  vesicular ;  raw,  weeping 
spots  are  thus  formed,  and  have  a  very  disfiguring  appearance. 
Such  eczema  may  occur  also  in  connection  with  disturbances  of 
menstruation,  when  the  menses  are  scanty  and  pale,  or  when  dys- 
menorrhcea  is  present. 

At  the  time  when  menstruation  ought  to  appear,  but  fails  to  do 
so,  sometimes  also,  when  menstruation  is  regular,  with  each  succes- 
sive period,  an  eruption  of  urticaria  takes  place ;  it  usually  disap- 
pears quickly,  but  in  some  cases  is  more  persistent ;  owing  to  the 
intense  itching  it  is  always  an  extremely  distressing  complaint. 
Sometimes  it  takes  the  form  of  urticaria  factitia,  in  which  the 
skin  reacts  to  every  kind  of  mechanical  stimulation,  such  as  rubbing, 
scratching,  or  pressure,  all  of  which  alike  lead  to  the  formation  of 
weals,  which  may  be  diffused  all  over  the  body.  Less  often  in  as- 
sociation with  disturbances  of  menstruation,  acute  oedema  or  erythe- 
ma are  observed. 

Finally,  we  must  mention  herpes  progenitalis,  a  rather  uncommon 
acute  condition  in  which,  with  violent  itching  and  burning  sensa- 
tion, intense  redness  and  cedematous  swelling  of  the  skin,  vesicles 
form  on  the  prseputium  clitoridis,  the  nymphae,  and  the  inner  sur- 
face of  the  labia  majora. 

Hygiene  During  the  Mcnarche. 

It  is  the  object  of  rational  hygiene  to  increase  the  resisting  power 
of  the  organism,  which  has  been  depressed  by  the  processes  of  the 
menarche,  in  order  that  the  increased  demands  made  by  the  awak- 
ened sexual  life  may  be  adequately  met. 

The  principal  means  for  this  purpose  are,  suitable  diet,  a  suitable 
mode  of  life,  and  the  employment  of  physical  therapeutic  measures, 


H2  THE  SEXUAL  LIFE  OF  WOMAN. 

among  which  strengthening  and  hardening  measures  are  to  be  pre- 
ferred. 

The  diet  should  be  at  once  as  richly  albuminous  as  possible  and 
readily  digestible,  there  should  be  several,  four  or  five,  meals  every 
day;  in  chlorotic  patients  food  should  be  taken  at  regular  intervals 
of  two  to  three  hours.  Meat  should  be  a  predominant  article  in  the 
diet,  but  fresh  vegetables  should  also  be  eaten  in  abundance  for  the 
sake  of  the  nutritive  salts  they  contain;  the  vegetables  rich  in  com- 
pounds of  iron,  such  as  spinach,  oats,  beans,  and  lentils,  are.  to  be 
recommended ;  fruit,  raw  or  cooked,  should  also  be  taken  in  con- 
siderable quantities.  The  evening  meal29  should  not  be  too  succulent 
or  too  plentiful ;  it  may  best  consist  of  soft-boiled  eggs,  an  omelette, 
or  milk.  Alcoholic  beverages  should  be  avoided  or  taken  in  minimal 
quantities ;  only  as  a  stomachic  may  a  glass  of  beer  or  of  light  wine 
be  recommended. 

Chlorotic  patients  should  even  at  their  first  breakfast29  have  a 
meal  rich  in  albumin,  such  as  a  considerable  helping  of  meat,  or  a 
beefsteak,  with  rolls,  butter,  and  tea  or  coffee.  Milk  should  be 
taken  in  small  quantities  only,  not  more  than  a  pint  to  a  pint  and  a 
half  daily ;  only  when  solid  food  cannot  be  tolerated  should  milk  be 
given  freely.  Beer  and  wine  are  often  of  value  in  chlorotic  girls 
from  their  stimulant  action  on  digestion  and  circulation.  Half  an 
hour's  rest  before  and  after  meals  is  useful. 

For  the  bill  of  fare  of  these  patients  I  recommend  especially: 
Roast  beef  and  veal,  underdone  beefsteak  a  1'Anglaise,  ham ;  roasted 
venison,  hare,  partridge,  grouse,  fieldfare,  hazel-hen,  ptarmigan, 
pheasant,  chicken,  pigeon,  turkey,  oysters;  asparagus,  cauliflower, 
and  spinach.  For  variety,  fish  or  shellfish  may  occasionally  be 
taken.  Sweetbread  in  soup  or  with  sauce  forms  a  very  delicious 
and  easily  digestible  dish. 

Kahane  recommends  for  chlorotic  patients  the  systematic  use  of 
Bavarian  beer,  to  the  amount  of  about  two  pints  daily;  it  should, 
he  says,  be  a  beer  rather  dark  in  tint,  full-brewed,  rich  in  malt,  but 
containing  a  comparatively  small  proportion  of  hops,  alcohol,  and 
carbonic  acid.  Ja-worski  has  recommended  a  dietetic  iron-beer,  con- 
taining 4.7  per  cent,  of  alcohol  and  from  0.0317  to  0.0644  Per  cent- 
of  iron. 

When  girls  are  at  the  same  time  anaemic  and  very  thin,  fat-con- 
taining foods  must  be  taken  in  abundance,  such  as  milk,  butter,  and 

29  It  must  be  remembered  that  these  dietetic  dire'ctions  are  for  German  and 
Austrian  middlerclass  people,  the  arrangement  of  whose  meals  differs  from 
ours  considerably.  The  usual  meals  and  hours  are :  Early  breakfast,  coffee 
and  rolls,  at  8  or  earlier;  second  breakfast,  a  more  substantial  meal,  at  10; 
mid-day  dinner,  the  principal  meal,  at  I  or  2  p.  M.;  afternoon  coffee,  at  4; 
supper  at  8  p.  M. —  TR. 


THE  SEXUAL  EPOCH  OF  THE  MENARCHE.  113 

cream;  also  large  quantities  of  carbohydrates.  Farinaceous  foods, 
rice,  potatoes,  arrowroot,  sago,  tapioca,  oatmeal,  barley  meal,  car- 
rots, turnips,  sweet  fruits,  grapes,  dates,  pippins,  plums,  pears,  and 
preserved  fruits  —  all  these  must  appear  at  table  more  frequently 
than  usual;  beverages,  in  addition  to  milk,  that  are  suitable  are 
chocolate  and  cocoa,  Bavarian  beer,  and  sweet,  heavy  wines. 

The  diet-table  of  such  thin  chlorotic  patients  should  be  as  follows : 

First  breakfast,  7.30  to  8  A.  M.  :  Coffee  or  cocoa  with  milk,  or  a 
pint  of  milk,  white  bread  and  butter,  honey.  Second  breakfast,  10 
A.  M.  :  Half  a  pint  to  a  pint  of  milk,  egg  and  bread  and  butter,  or 
sandwiches  of  sausage,  ham,  or  roast  meat.  Mid-day  dinner,  i  A.  M.  : 
Soup,  roast  meat  with  vegetables  and  potatoes,  or  fish  may  take 
the  place  of  the  soup,  sweets  to  follow.  Afternoon,  4  p.  M.  :  Coffee 
with  milk,  or  a  pint  of  milk,  with  bread  and  butter.  Supper,  7.30 
p.  M., :  A  plate  of  meat  with  accessories.  Evening,  9  p.  M.  :  A  glass 
of  milk. 

In  the  treatment  of  the  anaemic  form  of  obesity,  to  which  chlorotic 
patients  of  the  better  classes  are  subject,  in  consequence  of  sedentary 
habits  and  overfeeding,  the  diet  must  be  so  arranged  that  albumins 
predominate,  whilst  carbohydrates  should  be  given  sparingly,  and 
as  little  fat  as  possible.  As  the  average  quantities  of  the  food  ele- 
ments required  in  such  cases,  I  suggest,  200  grammes  of  albumin, 
12  grammes  of  fat,  and  100  grammes  of  carbohydrate. 

The  quantity  of  fluid  taken  must  be  as  small  as  possible,  since 
the  deprivation  of  water  may  result  in  a  proportionate  increase  in 
the  solid  constituents  of  the  blood,  and  thus  increase  its  haemoglobin- 
richness. 

The  amount  of  physical  exercise  taken  by  young  girls  at  this 
period  of  life  must  vary  according  to  the  circumstances  of  each 
individual  case.  In  general,  we  may  recommend  for  them  much 
active  movement,  especially  in  the  open  air,  in  order  to  counteract 
the  effects  of  sedentary  habits  and  confinement  in  close  rooms. 
Chlorotic  patients  must,  however,  be  careful  to  avoid  overdoing 
their  exercise,  and  in  some  cases  it  will  be  necessary  to  limit  the 
amount  of  this  very  strictly.  In  severe  cases  of  chlorosis,  Noth- 
nagel,  Hayem,  and  other  authorities  recommend  complete  rest  in  bed 
-for  from  four  to  six  weeks.  This  rest-cure  can  be  carried  out  as  far 
as  possible  .in  the  open  air,  and  can  be  combined  with  systematic 
massage  and  the  use  of  passive  movements. 

8 


THE  SEXUAL  LIFE  OF  WOMAN. 


I    have   drawn   up   the    following   diet-table    for  obese   chlorotic 
patients : 


Quantity  in 
Grammes. 

CONTAINS  OF 

Albumin. 

Fat. 

Carbohydrates. 

Morning: 

IOO 

150 
30 

IOO 
2OO 
50 
50 
150 

120 
25 

200 

25 
.      150 
30 

38.2 
0-45 

2-9 

i.i 
76.4 
0.8 

4.8 

i-7 

A  cup  of  tea     

0.9 
18.0 

5-7 

White  bread  

O.2 

i-5 
3-4 

0.2 
0.4 

Mid-day: 
Meat  soup  

Roast  meat  
Vegetables      

4.2 

30.0 

I.O 

1-7 
15.0 

White  bread.  

Afternoon: 
A  cup  of  coffee  

0.2 
2-4 

46.4 
0.4 

0.67 
O.2 

3-4 

O.I 

White  bread  

Evening: 
Roast  meat     

Vegetables  

2.1 

I.O 

18.0 

Wine  

White  bread  

2-9 

O.2 

Total  
Contains  about  1300  cal 

1380 

206.97 

II.Q2 

97.6 

ories. 

For  young  girls  at  this  period  of  life  systematic  gymnastic  exer- 
cises are  usually  valuable,  not  only  for  strengthening  the  muscular 
system  and  improving  the  physique  during  these  years  of  growth, 
but  also  for  assisting  the  functions  of  respiration,  circulation,  and 
digestion.  Beginning  with  the  simplest  and  easiest  exercises  of 
chamber  gymnastics,  the  girl  gradually  proceeds  to  more  difficult 
and  elaborate  exercises  and  to  the  use  of  medico-mechanical  ap- 
paratus. 

The  clothing  of  young  girls  at  the  time  of  the  menarche  must 
receive  attention  to  this  extent,  that  all  articles  of  clothing  should  be 
rejected  which  increase  the  tendency  already  existing  to  hypersemia 
of  the  genital  organs  or  offer  any  hindrance  to  the  circulation  in 
general.  Above  all,  the  physician  must  take  his  part  in  the  contest 
so  long  and  so  vainly  urged  against  the  corset.  But  further,  all 
tight  clothing,  such  as  restricts  the  freedom  of  movement  of  the 
thorax  and  the  abdomen,  tight  collars,  and  tight  garters  —  all  these 
must  be  forbidden ;  moreover  excessively  warm  underclothing,  of 
the  lower  extremities  especially,  which  may  stimulate  the  genital 
organs,  must  also  be  prohibited. 


THE  SEXUAL  EPOCH  OF  THE  MENARCHE.  115 

As  regards  the  night  hours,  a  thick  feather  bed  is  unsuitable. 
The  young  girl  should  sleep  on  a  hair  mattress,  and  the  bed  clothing 
should  be  light.  Eight  to  nine  hours  sleep  is  sufficient ;  in  the  words 
of  the  English  proverb,  "  early  to  bed  and  early  to  rise,  is  the  way 
to  be  healthy,  and  wealthy,  and  wise." 

To  live  by  rule,  with  regular  hours  of  work  and  suitable  pauses  for 
rest,  is  of  great  importance.  Among  the  well-to-do  classes  also 
care  should  be  taken  that 'the  adolescent  girl  takes  moderate  physical 
exercise  for  several  hours  daily ;  she  should  go  for  a  good  walk,  and 
not  spend  hour  after  hour  recumbent  upon  a  sofa  in  idle  reverie. 
Sitting  for  too  long  a  time,  whether  engaged  in  sewing  or  at  the 
piano,  is  harmful;  working  at  the  sewing-machine  is  permissible 
for  short  periods  only,  and  is  indeed  at  this  period  of  life  better 
altogether  avoided.  Bicycling  is  also  an  unsuitable  exercise  at  this 
age  and  readily  leads  to  masturbation.  Lawn  tennis  and  croquet, 
on  the  other  hand,  are  very  suitable  active  open-air  games;  in 
winter,  skating  may  be  indulged  in  if  proper  precautions  are  taken 
against  chill ;  in  summer,  swimming  and  rowing.  The  reading  of 
light  literature  should  be  kept  under  supervision ;  equivocal  novels, 
such  as  may  give  rise  to  erotic  reverie  and  sensual  excitement,  must 
be  strictly  forbidden.  A  watch  should  be  kept  for  any  indications 
of  the  habit  of  masturbation ;  and  if  the  habit  exists,  appropriate 
measures  should  be  taken. 

Hydrotherapeutic  procedures  and  baths  are  of  great  hygienic  and 
therapeutic  importance  for  girls  at  the  menarche.  In  healthy  girls 
at  this  period  of  life,  a  cold  sponge-bath  lasting  one  or  two  minutes, 
the  temperature  of  the  water  ranging  from  10°  to  20°  C.  (50°  to 
63°  F.),  taken  either  on  rising  in  the  morning  or  immediately  before 
going  to  bed,  is  a  valuable  means  for  hardening  the  whole  body ; 
equally  useful  are  cold  shower-baths,  lasting  from  a  few  seconds  up 
to  half  a  minute.  If  the  girl  is  somewhat  anaemic,  it  will  be  well 
for  her  to  take  a  glass  of  warm  milk  or  a  cup  of  tea  half  an  hour 
before  the  bath,  in  order  to  guard  against  too  great  an  abstraction 
of  heat.  Cold  bathing  in  rivers,  when  available,  may  also  be  recom- 
mended. In  cases  in  which  a  considerable  degree  of  anaemia  or 
chlorosis  is  present,  cold  baths  and  every  form  of  strong  mechanical 
stimulation  by  the  use  of  water,  douches  and  the  like,  are  to  be 
avoided,  since  we  have  to  fear  both  excessive  abstraction  of  heat  and 
overstimulation  of  the  nerves.  In  such  anaemic  'and  chlorotic 
patients,  either  partial  washing  with  lukewarm  water  or  general 
lukewarm  baths,  the  temperature  of  which  may  be  gradually  and 
cautiously  lowered,  either  on  rising  or  at  bedtime,  have  a  refreshing 
and  stimulating  effect. 

In  girls  who  are  in  other  respects  healthy,  but  in  whom  the  men- 


n6  THE  SEXUAL  LIFE  OF  WOMAN. 

arche  is  delayed,  and  in  whom  menstruation,  when  begun,  has  been 
scanty  and  irregular,  cold  sitz-baths  of  short  duration,  the  abdomen 
being  simultaneously  douched  from  a  considerable  height,  or  cold 
shower-baths  in  combination  with  powerful  abdominal  douches,  are 
often  of  value. 

Recently,  hot  air  and  vapor  baths  have  been  especially  recom- 
mended for  girls  suffering  from  chlorosis,  at  first,  by  Schoh  and 
Schubert,,  in  association  with  phlebotomy,  but  also  without  this. 
Kilhne,  for  example,  has  seen  the  most  satisfactory  results  follow 
the  simple  use  of  sudatory  baths  in  cases  of  chlorosis ;  improvement 
was  manifested  by  an  increase  in  the  corpuscular  richness  of  the 
blood,  an  increase  in  the  haemaglobin-richness,  and  an  increase  in 
the  body-weight.  In  cases  of  chlorosis,  Traugott  also  has  seen 
favorable  results  follow  the  use  of  hot-air  baths  and  the  consequent 
diaphoresis. 

Still  more  recently  Dehio  and  especially  Rosin  have  recommended 
hot  baths  for  girls  suffering  from  chlorosis.  In  fifty  cases  of 
chlorosis,  in  which  other  methods  of  treatment  had  given  negative 
results,  Rosin  gave  three  times  a  week  baths  at  a  temperature 
of  40°  C.  (104°  F.),  lasting  at  first  a  quarter  of  an  hour,  but  later 
half  an  hour.  After  the  bath,  in  those  strong  enough  to  bear  it,  a 
very  short  cold  douche  or  cold  sponging  followed ;  then  the  patient 
had  to  lie  down  for  an  hour.  The  treatment  was  carried  out  for 
from  four  to  six  weeks.  Each  bath  by  itself  had  a  notable  refresh- 
ing effect  in  these  patients,  and  at  the  end  of  the  course  most  of  the 
cases  exhibited  an  improvement  in  all  their  symptoms,  such  as  other 
methods  of  treatment  had  failed  to  produce. 

The  favorable  influence  exercised  by  these  hot  baths,  as  by  steam 
bath-cabinets,  light  baths,  sun  baths,  wet  packing,  and  similar 
sudorific  measures,  may  in  part  be  explained  by  the  dehydration  of 
the  system  that  is  thus  effected ;  whilst  those  who  maintain  the  auto- 
intoxication theory  of  chlorosis  may  regard  the  diaphoresis  as  a 
means  for  the  elimination  of  noxious  substances  from  the  body. 

Bathing  in  water  aerated  with  carbonic  acid  may  be  recommended 
for  patients  suffering  from  anaemia  and  chlorosis  at  this  period  of 
life,  for  the  reason  that  such  baths  can  be  tolerated  at  a  lower  tem- 
perature than  baths  of  ordinary  water.  The  natural  mineral  waters 
containing  free  carbonic  acid,  and  chalybeate  waters  rich  in  car- 
bonic acid,  when  used  as  baths,  are  effective  principally  in  virtue 
of  the  carbonic  acid  they  contain,  which  stimulates  the  skin ;  this 
stimulus  being  conducted  by  the  nervous  system  from  the  periphery 
to  the  nerve-centres,  is  reflected  thence,  and  by  irradiation  exercises 
a  quickening  effect  on  all  the  processes  of  nutrition.  These  baths 
are  usually  taken  at  a  temperature  progressively  reduced  from  32°  C. 


THE  SEXUAL  EPOCH  OF  THE  MENARCHE.  117 

to  25°  C.  (90°  F.  to  77°  F.),  and  each  bath  lasts  from  ten  to  twenty 
minutes;  they  are  in  most  cases  taken  every  other  day  only.  For 
young  girls  in  whom  the  menarche  is  delayed,  also  for  chlorotic 
patients  with  amenorrhoea  and  neuralgic  manifestations,  chalybeate 
peat  baths  are  indicated,  which  influence  the  peripheral  nerves  by  the 
exercise  of  a  gentle  yet  considerable  thermic  stimulus.  These  chaly- 
beate peat  baths  have  further  been  shown  to  increase  the  haemo- 
globin-richness, the  corpuscular  richness,  and  the  specific  gravity  of 
the  blood,  transitorily  after  each  bath,  but  to  some  extent  perma- 
nently also,  a  certain  increase  enduring  after  the  course  is  over. 

Young  girls  suffering  from  disturbances  of  their  general  health 
dependent  upon  a  scrofulous  or  rachitic  habit  of  body  may  with 
advantage  be  sent  to  brine  baths,  especially  to  such  as  are  situated 
in  the  Alps  or  other  mountainous  regions.  These  weakly,  lymphatic, 
scrofulous  girls,  suffering  from  scanty  or  irregular  menstruation, 
may  also  practice  sea-bathing  with  advantage,  especially  at  watering 
places  on  the  sea  coast,  where  the  waves  are  powerful.  In  such 
cases,  however,  it  is  advisable  in  the  first  instance  to  take  artificially 
warmed  sea-water  baths,  before  proceeding  to  actual  sea-bathing. 

If  the  sensibility  of  a  chlorotic  patient  is  so  great  that  she  can 
endure  neither  peat  baths  nor  carbonic  acid  containing  mineral 
water  baths,  we  must  add  to  the  latter,  in  order  to  make  their  action 
milder,  decoctions  of  chamomile,  wheat  bran,  malt,  and  the  like. 

In  cases  in  which  nervous  symptoms  predominate,  with  an 
apathetic,  melancholic  frame  of  mind,  aromatic  herb  baths  are  some- 
times useful.  For  this  purpose  such  herbs  should  be  employed  as 
contain  a  notable  quantity  of  ethereal  oils,  such  as  sage  (salvia  of- 
ficinalis),  wild  thyme  (thymus  serpyllum),  hyssop  (hyssopus  offi- 
cinalis),  wild  marjoram  (origanum  vulgare),  rue  (ruta  graveolens), 
archangel  (archangelica  officinalis),  levisticum  (levisticum  offici- 
nale).  Equally  useful  are  the  balsamic  pine  needle  baths,  for 
which  the  fluid  obtained  by  the  distillation  of  pine  needles  (pinus 
sylvestris),  freshly  collected  day  by  day,  is  employed. 

As  regards  the  climatic  conditions  suitable  for  adolescent  girls 
suffering  from  the  disorders  of  the  menarche,  from  the  nervous 
conditions  associated  therewith,  and  from  chlorosis,  residence  either 
in  the  mountains  or  at  the  seaside  is  especially  to  be  recommended. 
An  altitude  of  about  1,200  metres  (4,000  feet)  is  the  most  suitable, 
being  that  at  which  the  peculiar  characteristics  of  mountain  climates 
are  most  fully  developed.  The  influence  of  such  a  climate  on 
hrematopoiesis  has  to  be  taken  into  consideration,  as  well  as  its 
special  influence  on  the  menstrual  function. 

Even  though  it  cannot  yet  be  regarded  as  fully  determined 
whether  the  increase  observed  by  Viault,  Egger,  and  Mercier,  in  the 


u8  THE  SEXUAL  LIFE  OF  WOMAN. 

corpuscular  richness  and  haemoglobin-richness  of  the  blood  in  conse- 
quence of  residence  in  a  mountain  climate,  is  lasting  or  merely 
transitory,  yet  it  is  certain  that  the  haematopoietic  organs  are  favor- 
ably influenced  by  such  residence,  and  that  the  good  results  are 
augmented  by  the  stimulating  effect  mountain  air  exercises  on  the 
appetite  and  the  digestion.  Lombard  has  moreover  observed,  that 
at  a  high  altitude  the  menstrual  flow  is  more  abundant  and  dysmen- 
orrhoea  is. less  common.  For  young  girls,  therefore,  suffering  from 
irritable  conditions  of  the  heart,  increased  frequency  of  the  pulse,  or 
increased  arterial  tension,  and  for  those  also  in  whom  the  resisting 
power  of  the  organism  appears  deficient,  a  visit  to  a  mountain  health 
resort  situated  amid  forests  may  be  recommended.  For  scrofulous 
girls  a  visit  to  the  coast  of  the  North  Sea  is  especially  suitable.  For 
the  slighter  forms  of  anaemia,  a  sea  voyage,  in  which  the  benefits  of 
sea  air  can  be  obtained  more  fully,  and  for  a  longer  period,  may  be 
advised ;  but  such  a  voyage  is  quite  unsuitable  for  those  suffering 
from  severe  anaemia  or  chlorosis. 

Such  very  weakly,  intensely  anaemic  and  chlorotic  patients  should 
spend  the  winter  in  some  southern  health"  resort. 

The  skin,  in  which  disturbances  so  readily  occur  at  the  time  of 
the  menarche,  requires  careful  attention,  all  the  more  because  it  is 
precisely  at  this  age  that  young  girls  have  the  greatest  need  of  their 
personal  charms.  The  skin  of  the  face,  which  is  often  disfigured  by 
comedones  and  acne,  must  be  carefully  guarded  against  the  accumu- 
lation of  sebum  in  the  sebaceous  glands  by  sedulous  washing  with 
warm  water  and  a  good  soap.  If  the  seborrhoeic30  process  in  these 
glands  becomes  at  all  severe,  ordinary  soaps  are  unsuitable,  and  a 
potash  soap  must  be  used,  such  as  sapo  viridis,  or  spiritus  saponatus 
kalinus,  which  have  great  power  of  dissolving  fats. 

The  best  way  of  dealing  with  seborrhoea  is  according  to  Spictschka 
and  Griinfeld  the  following:  The  washing  is  best  effected  in 
the  evenings,  when  the  skin  will  not  again  for  many  hours 'be  ex- 
posed to  the  fresh  air,  to  wind,  or  to  dust.  Pour  into  a  basin  about 
a  pint  of  warm  water  and  add  from  one  to  two  teaspoonfuls  of 
spirit  of  soap  (equivalent  to  the  linimentum  saponis  of  the 
British  Pharmacopoeia)  or  as  much  soft  soap  as  can  be  taken  up  on 
the  end  of  a  table-knife.  The  water  is  then  stirred  vigorously  till  a 
good  lather  is  formed,  and  with  the  water  and  the  lather  the  face  is 
thoroughly  washed.  The  skin  must  then  be  carefully  dried,  and 
thereafter  it  is  well  to  smear  it  with  some  greasy  material,  such  as 
boric  vaseline,  in  order  to  prevent  the  plugging  of  the  pores  with 

10  Regarding  the  significance  attached  by  the  author  to  the  words  sflorrhoea 
and  scborrhoeis,  see  note  to  page  107. 


THE  SEXUAL  EPOCH  OF  THE  MENARCHE.  119 

dust,  and  to  protect  the  sebum  subsequently  exuded  from  dessication. 
On  the  next  day  the  washing  should  be  repeated  only  if  the  face 
has  become  covered  with  sebum  within  an  hour  or  two  after  the 
first  washing-.  If  the  exudation  is  less  free,  the  eyes  only  should  be 
washed  with  fresh  water,  whilst  the  rest  of  the  face  should  not  be 
wetted,  but  merely  be  wiped  with  a  dry  face  towel  lightly  dusted 
with  toilet  powder,  in  order  to  remove  any  accumulation  of  sebum. 

The  skin  of  the  genital  regions  must  be  carefully  cleansed,  espe- 
cially in  cases  in  which  there  is  a  tendency  to  hypersecretion  of  the 
sebaceous  glands,  to  eczema,  or  to  herpes  progenitalis ;  subsequently 
it  should  be  powdered,  and  pads  of  absorbent,  cotton-wool  dusted 
with  toilet  powder  should  be  placed  in  the  labial  furrows. 

It  is  of  great  importance  that  in  girls  at  this  time  of  life  gyneco- 
logical examination  should  be  undertaken  only  in  cases  of  the  utmost 
need,  and  this  restriction  should  be  especially  inflexible  in  the  case 
of  girls  with  a  neuropathic  predisposition.  Instances  have  been 
observed  in  which  a  vaginal  examination,  the  introduction  of  a 
vaginal  speculum,  or  the  use  of  the  uterine  sound,  has  determined 
the  onset  of  a  psychosis.  Still  more  does  what  has  been  said  hold 
true  of  local  treatment  in  gynecological  cases.  Repeated  passage  of 
the  uterine  sound,  cauterization  of  the  cervix,  and  the  manipulations 
of  gynecological  massage,  make  a  very  deep  impression  upon  the 
mind  of  a  girl,  and  give  rise  to  morbid  ideas  and  erotic  storms,  so 
that  even  in  those  with  a  powerful  constitution,  various  neuroses, 
neurasthenic  states,  and  even  mental  disorders  may  result.  If  in 
such  cases,  especially  hi  girls  of  a  neuropathic  temperament,  gyne- 
cological treatment  is  quite  indispensable,  a  single,  though  energetic, 
operative  procedure  is  to  be  preferred  to  a  number  of  successive, 
though  taken  singly  less  extensive,  manipulations  of  and  in  the 
female  genital  organs.  The  importance  of  this  proposition  has 
been  repeatedly  established.  Sanger,  for  instance,  points  out  as  a 
fact  to  be  regretted  that  uterine  cauterization  with  mild  caustics  is 
far  too  frequently  undertaken ;  and  Odebrecht  from  the  same  stand- 
point proclaims  the  advantage  of  a  single  curetting  as  compared  with 
milder  intra-uterine  impressions  repeated  during  a  course  of  treat- 
ment lasting  many  months.  On  the  other  hand,  the  physician  must 
bear  in  mind  the  fact,  established  by  the  record  of  a  very  large  num- 
ber of  cases,  that  in  women  predisposed  to  psychoses  severe  gyneco- 
logical operations  are  apt  to  lead  to  the  actual  appearance  of  mental 
disorders,  or  to  the  exacerbation  of  mental  disorders  which  have 
previously  been  very  mild  or  have  merely  threatened  to  appear. 
Careful  consideration  is  needed,  on  the  one  hand  as  regards  the 
severity  of  the  disease  of  the  genital  organs,  and  on  the  other  as 
regards  the  resisting  power,  temperament,  and  constitution  of  the 


I2O  THE  SEXUAL  LIFE  OF  WOMAN. 

girl  concerned,  and  in  many  cases  a  consultation  between  the  gyne- 
cologist and  the  neurologist  is  expedient. 

A  very  powerful  influence  on  the  physical  and  moral  well-being 
of  the  girl  at  puberty  is  exercised  by  her  domestic  upbringing. 
The  general  truth  of  Goethe's  saying,  that  the  circumstances  into 
which  we  are  born  exercise  a  determining  influence  on  the  whole 
life,  being  admitted,  we  have  to  remember  that  this  applies  with 
especial  force  in  the  case  of  girls. 

The  educational  views  which  obtain  at  the  present  day  among 
the  upper  ten  thousand,  are  by  no  means  calculated  for  the  produc- 
tion of  a  woman  healthy  in  body  and  sound  in  mind.  From  the 
time  when  the  young  girl  becomes  sexually  developed,  the  claims 
which  society  makes  upon  her  become  pressing.  Every  day,  by  a 
number  of  stimuli,  her  curiosity  and  her  desires  are  directed  toward 
sexual  matters.  Visits  to  museums,  picture  galleries,  and  theatres, 
the  perusal  of  modern  romances,  the  free  mingling  of  the  sexes  in 
all  places  of  amusement  —  all  these  combine  to  awaken  prematurely 
an  instinct  to  which  the  "•  old  fashioned "  methods  of  education 
allowed  a  much  more  prolonged  slumber.  In  other  cases,  the 
mother's  supervision  of  the  developing  girl  is  hindered  and  rendered 
insufficient  because  the  mother  herself  is  claimed  by  her  society 
duties  and  taken  much  away  from  her  home.  In  addition,  the 
young  brain  is  overburdened  with  mental  work,  the  modern  idea  of 
the  equality  of  the  sexes  in  matters  of  love  is  instilled,  and  a  desire 
is  artificially  evoked,  and  is  matured  by  a  certain  idle  vanity,  to 
indulge  the  "  natural  "  instincts — to  manifest  sexual  passion  and 
to  indulge  it  to  excess  —  and  thus  the  modesty  so  natural  and  so 
becoming  to  young  girls  is  completely  lost.  Nourished  in  such  a 
soil,  neurasthenic  and  hysterical  states,  disorders  of  menstruation, 
and  masturbation,  cannot  fail  to  flourish. 

In  these  respects  also  a  change  is  requisite,  and  a  mode  of  up- 
bringing must  be  inculcated  from  which  everything  likely  to  inflame 
the  sexual  impulse  is  removed.  For  the  adolescent  girl  a  systematic 
alternation  of  work  and  recreation  must  be  arranged.  From  great 
entertainments  where  she  will  mix  with  young  men,  from  theatres, 
evening  parties,  and  balls,  the  young  girl  at  the  time  of  the  menarche, 
at  the  period  when  menstruation  commences,  must  as  far  as  possible 
be  kept  away,  and  such  pleasures  must  be  reserved  for  a  more 
advanced  stage  of  this  period  of  development.  Intellectual  over- 
strain, the  overtaxing  of  the  young  head,  must  be  avoided;  the 
acquirement  of  knowledge  must  take  place  gradually  and  slowly, 
and  in  a  manner  adapted  to  individual  peculiarities.  Intercourse 
with  female  friends  also  requires  supervision  in  respect  of  the 
moral  characteristics  of  these  latter.  Religious  reverie  must  be 


THE  SEXUAL  EPOCH  OF  THE  MENARCHE,  121 

avoided,  but  also  to  be  avoided  is  the  modern  nihilism  in  respect 
of  religion  and  good  morals.  Books  must  be  carefully  chosen  in 
order  that  the  imagination  may  remain  pure  and  in  order  that  girlish 
illusions  may  not  be  prematurely  destroyed.  Domestic  recreations 
in  the  way  of  games,  music,  singing,  painting,  and  other  forms  of 
artistic  culture,  are  of  importance  for  the  development  of  a  strenu- 
ous faculty  for  learning.  Travel  in  regions  where  the  scenery  is 
beautiful,  forms  a  most* valuable  means  for  the  ennoblement  of  the 
intellect  and  the  emotions. 

Additional  matters  demanding  attention  are,  as  already  men- 
tioned, the  suitability  of  the  diet,  and  proper  physical  exercise.  All 
stimulating  articles  of  food  are  to  be  avoided,  the  excessive  use  of 
meat  is  to  be  forbidden,  and  a  sufficient  mixed  diet,  containing  both 
animal  and  vegetable  substances,  is  to  be  prescribed.  Tea  and 
coffee  should  be  taken  as  sparingly  as  possible,  and  alcoholic  bever- 
ages must  be  absolutely  prohibited.  The  regulation  of  the  bowels 
is  of  great  importance.  Young  girls  should  accustom  themselves 
to  evacuate  the  bowels  every  day  at  a  fixed  hour,  the  best  time  to 
adopt  being  either  immediately  on  rising  or  just  after  breakfast. 
Constipation  is  very  apt  to  lead  to  the  production  of  irritable  con- 
ditions of  the  genital  organs. 

We  can  point  out  as  a  happy  instance  of  modern  progress  that 
the  practice  of  certain  physical  exercises  has  actually  become  the 
fashion  for  young  girls.  Gymnastics,  with  or  without  apparatus, 
swimming,  skating,  and  lawn  tennis,  involve  a  number  of  bodily 
movements  advantageous  for  the  health ;  and  in  connection  with 
most  of  these  the  enjoyment  of  fresh  air  offers  an  additional  favor- 
able influence.  Bicycling,  however,  at  this  period  -of  life  is  open  to 
many  objections,  not  only  on  account  of  the  likelihood  of  direct 
injury  to  the  genital  organs  now  in  course  of  development,  but  also 
on  account  of  the  impulse  it  produces  toward  onanistic  manipu- 
lations. 

Especial  attention  must  be  paid  to  the  clothing,  regarding  which 
the  requirements  of  fashion  so  often  conflict  with  those  of  hygiene, 
the  victory,  unfortunately,  in  most  cases  falling  to  the  former.  The 
period  of  the  menarche  is  indeed  usually  regarded  as  the  proper 
time  for  the  young  girl  to  begin  wearing  a  corset,  if  it  has  not  been 
worn  before.  In  this  connection  M.  Runge  makes  the  significant 
remark :  "As  long  as  bodice  and  skirt  form  the  two  principal  articles 
of  woman's  clothing,  the  corset  or  some  similar  article  cannot  be 
dispensed  with.  The  vicious  features  in  the  corset  are  its  con- 
striction of  the  thorax,  with  the  object  of  giving  the  woman  a 
'  figure,'  and  the  introduction  into  its  substance  of  strips  of  whalebone 
or  steel  in  order  to  give  firmness  to  the  figure.  The  harm  done  by  the 


122  THE  SEXUAL  LIFE  OF  WOMAN. 

former  feature,  the  compression  of  the  abdominal  viscera,  the  corset 
liver  (lacing  liver,  constricted  liver,  Ger.  Schniirlcber),  the  movable 
kidney,  etc. —  all  are  so  well  known  that  they  need  not  be  particu- 
larly described.  But  the  strong  pressure  from  above  has  a  dele- 
terious effect  upon  the  internal  genital  organs  also,  leading  to 
passive  hyperaemia  and  to  displacements.  The  '  bones  '  of  the  corset 
take  part  in  the  compression,  and  they  replace  the  functions  of  the 
muscles  of  the  back.  If  a  woman  who  has  -long  worn  a  corset  lays 
it  aside  later  in  life,  she-  complains  that  she  is  no  longer  able  to  hold 
herself  upright.  In  consequence  of  insufficient  work  the  musdes 
of  the  back  have  become  incapable  of  keeping  the  back  straight. 
The  corset,  then,  must  neither  constrict  the  body,  nor  must  it  con- 
tain '  bones.'  An  article  of  clothing  analogous  to  the  corset  is, 
however,  required  for  the  support  of  the  skirt  and  the  petticoats  that 
clothe  the  lower  limbs.  These  latter  are  usually  fastened  by  means 
of  bands  which  encircle  the  body  above  the  crest  of  the  ilium. 
In  order  to  give  these  bands  a  sufficient  hold,  this  region  of  the  body 
is  compressed  by  the  corset.  The  burden  of  skirt  and  petticoats  is 
thus  borne  by  a  furrow,  above  the  pelvis  and  below  or  in  the  region 
of  the  asternal  or  false  ribs,  which  is  in  great  part  artificially  pro- 
duced. All  this  is  bad.  In  order  to  avoid  the  necessity  for  any 
constriction,  the  petticoats  should  be  fastened  to  the  corset,  and  this 
latter  should  be  supported  from  the  shoulders  by  means  of  shoulder- 
straps  or  braces  crossing  one  another  behind.  No  constriction  of 
the  thorax  then  occurs,  and  if  the  corset  has  suitable  supporting 
pouches  for  the  breasts,  and  the  wearer  is  accustomed  to  hold  herself 
erect,  the  figure  of  a  well-formed  woman  thus  attired  is  far  from 
unpleasing,  and  is,  above  all,  natural.  If  the  weight  of  skirt  and 
petticoats  is  too  great  to  be  borne  by  the  shoulders,  the  burden 
can  be  divided,  some  being  fastened  to  the  corset,  others  tied  round 
the  waist.  This  method  is  less  to  be  commended,  but  may  be  re- 
garded as  a  permissible  middle  course.  If  chemise  and  drawers  are 
woven  in  one  piece,  as  in  the  '  combination '  under  garment,  there 
is  one  article  the  less  to  be  attached  to  the  corset.  Recently  a 
number  of  corsets  and  articles  of  clothing  have  been  made  in  accord- 
ance with  these  principles. 

"  The  growing  girl,  then,  may  wear  a  soft  corset  with  shoulder- 
straps,  made  to  measure,  to  which  all  the  garments  clothing  the 
parts  below  the  waist  should  be  made  to  fasten.  It  must  unfor- 
tunately be  admitted  that  this  rational  mode  of  arranging  the  cloth- 
ing cannot  be  adapted  to  the  '  low  dress '  which  etiquette  demands 
on  so  many  occasions  for  evening  wear,  since  with  the  latter  the 
shoulder-straps  cannot  be  worn. 

"  It  is  most  unhygienic  for  women  to  wear,  as  they  so  often  do, 


THE  SEXUAL  EPOCH  OF  THE  MENARCHE  123 

drawers  that  are  widely  open.  Both  cleanliness  and  the  need  for  an 
equable  warmth  demand  that  these  garments  should  be  closed  be- 
tween the  thighs,  not  to  speak  of  other  reasons." 

In  order  to  diminish  the  sexual  impulse  in  girls  at  the  menarche, 
where  this  impulse  has  developed  prematurely  or  is  abnormally  in- 
tense, and  even  in  later  years  with  the  same  end  in  view,  it  is  neces- 
sary, not  merely  that  the  diet  should  be  suitable  and  non-stimulating 
and  that  the  educational  environment  should  be  satisfactory,  but 
above  all  that  there  should  be  regular  occupation  and  regular  physical 
activity.  Ribbing  rightly  calls  attention  to  his  experience  in  dealing 
with  animals,  that  equally  in  the  case  of  the  stallion  and  of  the 
mare,  the  whole  of  life  may  without  difficulty  be  passed  in  complete 
abstinence  from  sexual  gratification,  provided  that  the  diet  is  suit- 
able, being  neither  too  rich  nor  too  meagre,  and  that  the  animal  has 
regular  occupation  of  a  nature  and  degree  adapted  to  its  powers. 
In  these  animals  a  certain  amount  of  disquiet,  of  restlessness,  of 
sulky  irritability,  etc.,  may  indeed  be  noticed  at  times,  but  these 
manifestations  are  to  be  overcome  by  mingled  gentleness  and  firm- 
ness, aided  now  and  again  also  by  mild  chastisement,  but  altogether 
without  any  severity.  "  Chastity,"  says  Oestcrlen,  "  is  possible  only 
when  the  mode  of  life  is  simple  and  regular,  and  is  characterized  by 
appropriate  self-command  and  frugality.  For  this  reason  it  is  rarely 
encountered  in  palaces  and  similar  places,  in  which  from  youth 
onwards  every  one  can  do  what  he  pleases;  but  just  as  little  is  it 
really  practicable  amid  conditions  of  lack  of  culture,  rudeness,  and 
poverty." 

From  the  point  of  view  of  education,  what  Morcau  wrote  a  hun- 
dred years  ago  is  of  importance :  "  In  the  ordinary  course  of  nature 
the  young  woman  at  the  time  of  the  first  appearance  of  menstruation 
is  still  in  full  possession  of  those  amiable  qualities  of  blamelessness 
and  chastity  which  we  are  accustomed  to  denote  by  the  term  moral 
virginity.  To  an  honorable  and  pure-minded  man  this  beautiful 
attribute  of  budding  womanhood  is  much  dearer  and  more  estimable 
than  physical  virginity.  By  libertines  only  is  the  latter  regarded 
as  a  most  valuable  possession,  since  it  furnishes  a  powerful  stimulus 
to  their  jaded  imaginations.  But  moral  virginity  and  physical 
virginity  are  not  always  and  necessarily  associated,  for  either  can 
be  present  in  the  absence  of  the  other.  Physical  virginity  may  be 
destroyed  by  diverse  forms  of  violence,  and  yet  moral  virginity  may 
remain  pure  and  uninjured  amidstvits  ruins.  Thus  the  two  are 
widely  different  one  from  the  other,' widely  different  also  are  they  in 
value  and  significance." 

What  Eulenburg  says  regarding  the  prophylaxis  of  sexual  neuras- 
thenia in  general  is  true  regarding  the  sexual  life  of  the  girl  at  this 


124  THE  SEXUAL  LIFE  OF  WOMAN. 

period  of  life.  "  What  is  needed,"  he  writes,  "  is  the  control  of 
educational  influences  with  these  ends  in  view,  that,  on  the  one  hand, 
the  sexual  excitability  of  developing  youth  shall  be  diminished  and 
kept  within  bounds,  and  that  nevertheless,  on  the  other,  the  urgently 
needed  enlightenment  shall  be  afforded  to  the  young  people  at  the 
proper  time  and  in  a  suitable  form.  How  these  aims  are  to  be 
effected  cannot  be  explained  in  generally  applicable  propositions. 
It  is  a  matter  which  must  be  left  to  the  tact  of  the  parents  and  of 
other  members  of  the  family,  who  will  be  guided  by  the  insight  they 
have  acquired  into  the  mental  life  of  those  concerned.  *  *. 

Children  inclined  to  onanism  must  be  carefully  supervised  by  day 
and  by  night;  they  must  be  protected  from  all  stimulating  things 
and  from  bad  company ;  in  boarding-schools  it  is  the  common  dor- 
mitories that  require  the  most  strict,  most  careful,  and  most  con- 
tinuous control.  In  the  case  of  auto-onanists,  female  as  well  as 
male,  we  must  enquire  into  the  possible  existence  of  local  stimulating 
influences,  among  which,  in  both  sexes,  oxyuris  must  be  men- 
tioned —  but  in  truth  it  is  rare  for  such  local  conditions  to  be  the 
exciting  cause  of  masturbation.  A  healthy  mode  of  life  in  respect 
of  clothing,  sleep,  and  diet,  and  the  systematic  practice  of  bodily 
exercises  to  the  point  of  considerable  fatigue,  are  the  most  effectual 
means  of  counteracting  the  noxious  propensity  to  onanism." 

A  high  degree  of  freedom  permitted  to  girls  from  a  very  early  age 
is,  as  Rousseau  already  maintained,  by  no  means  favorable  to  the 
preservation  of  virginity. 

A  wise  mother  or  a  wise  instructress  can  do  much  towards  the 
preservation  of  physical  and  moral  virginity,  by  enlightening  her 
daughter  or  pupil  at  the  right  time  and  in  a  proper  manner  as  to 
the  nature  of  the  sexual  processes,  and  their  significance  for  the 
whole  life  of  woman.  Ignorance  in  this  respect,  equally  with  pseudo- 
knowledge,  entails  many  dangers.  I  regard  it  as  indispensable  that 
the  adolescent  girl  should  in  good  time  learn  from  her  mother  the 
nature  of  menstruation,  lest  she  should  first  receive  enlightenment  in 
an  unfitting  manner  from  some  more  experienced  female  friend.  The 
mother  should  explain  that  the  impending  flow  of  blood  is  a  natural 
process,  unattended  by  danger,  but  indispensable  to  the  sexual  life, 
and  a  characteristic  part  of  the  process  of  "  growing  up." 

The  knotty  and  important  topic  of  how  the  young  girl  may  best 
receive  sexual  enlightenment  from  her  mother,  is  discussed  by  E. 
Stiehl  in  her  notable  work  "A  Maternal  Duty."  31  The  authoress 
points  out  that  this  enlightenment  must  not  take  place  suddenly 
and  without  apparent  motive,  but  that  the  mother  must  in  a  gentle 

W  Eine  M  utter pfiicht. 


THE  SEXUAL  EPOCH  OF  THE  MENARCHE.  125 

and  gradual  manner  introduce  to  her  child  the  secrets  of  nature.  A 
beginning  may  be  made  by  teaching  the  child  to  observe  the  nature 
.and  growth  of  plants;  then  she  may  be  led  to  interest  herself  in 
the  family  life  of  animals;  and  thus  an  easy  way  is  found  to  answer 
the  questions  connected  with  reproduction- — to  answer  them  in  a 
manner  at  once  true  and  befitting. 

Let  the  mother  indicate  to  her  child  the  methods  employed  by 
nature  for  the  preservation  of  the  life  of  the  young  plant;  let  her 
demonstrate  in  a  flower  the  stamens  and  the  pistil  as  male  and 
female  organs  respectively ;  and  let  her  explain  how  when  the 
pollen-grain  reaches  and  fertilizes  the  tiny  ovule  in  the  ovary,  this 
ovule  becomes  capable  of  development  into  a  large  seed  containing 
an  active  rudimentary  plant,  which  latter  itself  enlarges  to  become 
a  new  full-grown  specimen  of  its  kind.  The  opportunity  may  then 
be  seized  to  draw  attention  to  the  resemblance  between  the  little 
ovules  in  the  ovary  of  the  flower  and  the  minute  ova  by  means  of 
which  all  animal  life  reproduces  its  kind.  Proceeding  further,  an 
earnest  and  thorough  introduction  to  the  sanctity  and  responsibility, 
the  perils  and  duties,  of  the  sexual  life,  is  urgently  required  by  the 
young  girl  before  she  proceeds  either  to  marriage  or  to  an  econom- 
ically independent  mode  of  life. 

Not  only  in  America  and  England,  but  now  also  in  Germany, 
there  exist  excellent  books  which  may  actually  be  put  itfto  the 
growing  girl's  own  hands,  by  means  of  which  she  will  be  intro- 
duced in  an  intelligent  manner  to  a  knowledge  of  the  method  of 
reproduction  in  the  human  species. 

Often  enough,  when  the  mother  is  lacking  in  intelligence  or 
sympathy,  it  will  be  the  duty  of  the  physician  to  give  this  enlighten- 
ment to  the  young  girl.  The  interpreter  of  such  tidings  at  the  time 
of  love's  dawning  will  be  the  family  doctor,  to  whom  the  girl  and 
her  family  have  been  confidently  accustomed  to  turn  for  informa- 
tion regarding  the  bodily  state  and  well-being.  He  is  accustomed 
to  remove  many  a  veil  without  any  offense  to  maidenly  modesty. 
Many  sexual  disorders  and  much  sexual  aberration  may  thus  be 
prevented. 

Certain  definite  hygienic  rules  must  now  be  prescribed.  First  of 
all,  the  strictest  cleanliness  must  be  observed,  not  only  in  the  inter- 
vals, but  also  during  menstruation.  The  prejudice  against  chang- 
ing the  under  linen  during  the  flow  must  be  overcome,  and  care 
must  be  taken  that  at  this  time  the  external  genitals  are  washed  twice 
daily  with  water  at  a  temperature  of  26°  C  to  28°  C.  (about  80°  F.), 
and  a  wad  of  absorbent  cotton-wool  or  a  piece  of  clean  linen  (sponges 
are  not  to  be  used  for  this  purpose)  ;  any  article  of  underclothing 


126  THE  SEXUAL  LIFE  OF  WOMAN. 

that  becomes  soiled  with  blood  must  be  changed.  Most  useful  are 
the  so-called  "  sanitary  towels,"  made  of  sterilized  absorbent  cotton- 
wool, fastened  to  a  linen  band  which  surrounds  the  waist,  or  simple 
pads  of  absorbent  material  may  be  used,  kept  in  place  by  means  of 
a  bandage.  During  menstruation,  full  baths,  warm  or  cold,  are  to 
be  avoided,  likewise  long  walks,  riding,  long  journeys  by  rail, 
gymnastics,  with  or  without  apparatus,  skating,  lawn  tennis,  and 
bicycling;  dancing,  above  all,  must  be  prohibited,  since  it  involves 
a  combination  of  several  noxious  influences  —  the  very  active  move- 
ment, which  produces  hyperaemia  of  the  genital  organs,  sexual 
excitement,  loss  of  sleep,  long  hours  spent  in  close  rooms,  prolonged 
voluntary  retention  of  urine,  and  the  risk  of  a  chill.  Singing,  also, 
must  be  discontinued  during  menstruation,  since  otherwise  an  injury 
to  the  voice  is  very  likely  to  result.  A  certain  limitation  in  respect 
of  physical  and  mental  activity  is  indicated  as  a  general  precautionary 
measure  during  menstruation,  but  this  measure  must  not  be  pushed 
to  excess,  so  that  the  habit  is  acquired  of  resting  completely  during 
the  period,  passing  the  days  on  a  sofa.  The  favorite  practice,  in 
cases  of  scanty  menstruation,  of  taking  hot  foot-baths  is  to  be  re- 
jected. At  the  conclusion  of  each  menstrual  period,  however,  a  tepid 
bath  should  be  taken.  The  knowledge  we  have  now  acquired  of 
the  rhythmical  "  menstrual  wave  "  process  (see  p.  19  ct  scq.}  points 
to  the  practical  conclusion  that  the  physician  should  not  direct  his 
attention  to  the  actual  menstrual  period  only,  but  also,  and  more 
than  has  hitherto  been  customary,  to  the  premenstrual  period,  in 
which  temperature,  blood-pressure,  and  excretion  of  urea  attain 
their  acme ;  especially  should  this  be  done,  with  the  aim  of  pre- 
scribing suitable  hygienic  precautions,  in  cases  in  which  the  men- 
strual discharge  is  very  profuse  or  in  which  nervous  manifestations 
accompany  menstruation. 

Important  is  it  also  for  the  physician  to  take  precautions  against 
the  practice  by  young  girls  of  unduly  prolonged  voluntary  retention 
of  the  urine,  resulting  in  over-distension  of  the  bladder ;  also  against 
the  performance  of  very  active  movements  and  against  powerful 
muscular  efforts  when  the  bladder  is  in  a  distended  state.  All  of 
these  are  liable  to  result  in  displacements  of  the  uterus. 

During  menstruation  the  diet  should  be  sufficient,  but  free  from 
stimulating  elements.  When  the  menstrual  flow  is  greatly  in  excess, 
strong  tea  and  coffee,  wine,  and  beer  should  be  forbidden ;  conver- 
sely, when  menstruation  is  scanty,  an  invigorating  diet  is  especially 
indicated,  and  the  use  of  strong  wines.  According  to  the  investi- 
gations of  T.  Schroder,  in  order  to  maintain  the  nitrogenous  balance 


THE  SEXUAL  EPOCH  OF  THE  MENARCHE.  127 

during  menstruation,  it  is  necessary  to  give  the  following  daily  diet, 
representing  a  heat  value  of  2,013  to  2,076  calories : 

125—150  grammes  of  fowl. 

100  grammes  of  butter. 
125—140  grammes  of  white  bread. 
150  grammes  of  brown  bread. 
70-80  grammes  of  eggs. 
600  grammes  of  coffee. 
600  grammes  of  soup. 
560  grammes  of  Seltzer   water. 
20  grammes  of  salt. 


For  chlorotic  girls  the  following  diet  may  be  recommended  during 
menstruation.  Before  rising  a  pint  of  milk  should  be  taken  slowly, 
in  sips,  during  a  period  not  exceeding  half  an  hour ;  for  the  first 
breakfast  (see  note  to  p.  112),  tea  or  coffee  with  an  abundance  of 
milk,  a  considerable  portion  of  meat  (roast  beef,  cold  fowl,  cutlets, 
or  beefsteak)  ;  for  the  second  breakfast,  a  tumbler  of  milk,  bread, 
butter,  and  a  couple  of  eggs ;  for  midday  dinner,  a  good  helping  of 
fresh  meat  so  cooked  as  to  be  easily  digested,  green  vegetables, 
potatoes,  farinaceous  pudding,  stewed  fruit,  and  a  glass  of  bur- 
gundy or  claret ;  at  4  p.  M.,  coffee  and  bread  and  butter,  or  a 
tumbler  of  milk ;  at  7  P.  M.,  a  similar  meal  to  the  midday  dinner,  but 
lighter ;  no  supper.  In  this  diet-table,  which  represents  a  heat-value 
of  about  2,200  calories,  albumin  and  fat  are  present  in  abundance 
(182.8  grammes  albumin  and  763  grammes  fat),  but  carbohydrates 
in  small  quantity  only  (176.9  grammes). 

For  those  chlorotic  patients  who  find  it  difficult  to  digest  much 
butcher's  meat,  the  necessary  quantum  of  albumin  must  be  supplied 
by  increasing  the  amount  of  milk,  soup,  and  the  white  varieties  of 
flesh  (chicken  and  the  like),  giving  also  a  considerable  amount  of 
the  more  easily  digested  vegetables,  with  fruit,  beer,  and  a  little 
claret.  For  such  cases  Desque  has  drawn  up  the  following  diet- 
table,  representing  3,290  calories  and  containing  150  grammes  of 
albumin,  110.7  grammes  of  fat,  and  449.6  grammes  of  carbo- 
hydrate ;  meat  is  given  once  a  day  only : 

7. 30  A.  M. —  Half  a  pint  of  milk,  50  grammes  roll,  10  grammes  butter. 

10  A.  M. —  300  grammes  apples,  strawberries,  or  cranberries,  50  grammes  roll, 

10  grammes  butter. 

12.30  P.  M. —  200     grammes     of    beefsteak,     100   grammes    of   macaroni,    300 
grammes    of    bread,    400    grammes    of    spinach,    200   grammes 
of  stewed  apples  or  gooseberries. 
4P.M. —  200    grammes    vegetable-peptone-cocoa,    50    grammes    roll,    10 

grammes  butter. 

7. 30 P.M. —  200  grammes  rice-broth,  500  grammes  buttermilk,  100  grammes 
bread,  10  grammes  butter,  200  grammes  salad,  300  gramme:) 
uncooked  pears,  40  grammes  curds. 


128  THE  SEXUAL  LIFE  OF  WOMAN. 

In  cases  of  profuse  metrorrhagia  in  girls,  von  Wine k el  recom- 
mends in  addition  to  rest  in  the  recumbent  posture,  a  diet  containing 
large  quantities  of  fluid,  and  much  easily  assimilable  albuminous 
nutrient  material,  all  stimulating  articles  and  those  likely  to  cause 
nausea  and  vomiting  being  avoided.  He  gives  the  following  diet- 
table  : 

7  A.  M. —  250  grammes  of  milk. 

9  A.  M. —  250  grammes  of  bouillon,  I  egg,  20  grammes  of  brandy. 
II  A.  M. —  250  grammes  of  milk. 
I  P.  M. — 100  grammes  of  roast    meat,    250    grammes    of    rice-broth    with    5 

grammes  of    somatose,  and  150  grammes  of  claret. 
3  P.  M. —  250  grammes  of  milk. 
S  p.  M. —  I  egg,  20  grammes  of  brandy. 
7  P.  M. —  250  grammes  of  bouillon  or  white  soup  with  5  grammes  of  somatose. 

As  a  beverage  in  the  intervals,  weak  cold  tea  is  allowed.  When 
the  haemorrhage  has  ceased,  the  following  beverages  are  suitable : 
oatmeal,  cocoa,  Pilsener  beer  (one  pint  daily),  milk  (2  to  3  pints 
daily),  claret  (a  half  bottle  daily).  For  food,  the  lighter  varieties 
of  meat,  200  to  300  grammes  daily,  sweet-bread,  pigeon,  ham,  nutri- 
ent and  easily  digestible  vegetables,  spinach,  carrots,  and  pea-soup, 
may  be  recommended. 

In  cases  of  amenorrhcea  of  scanty  menstruation,  especially  when 
due  to  anaemia  or  to  underfeeding,  mental  excitement,  or  over- 
exertion,  warm  baths  at  a  temperature  of  28°  to  29°  R.  (90°  to 
92°  F.),  rubbing  the  body  with  wet  towels,  and  warm  sitz-baths, 
are  of  good  service. 

[NOTE:  Although  in  this  translation  the  English  equivalent?  of  the  measures 
used  on  the  Continent  have  as  a  rule  been  appended  in  parenthesis,  this  has 
not  been  thought  necessary  in  the  rase  of  the  diet-tables,  since  even  in  English 
works  these  are  commonly  stated  in  terms  of  the  metric  system.  It  may  here 
be  mentioned  that,  as  regards  fluid  measures,  250  grammes  (a  quarter  of  a 
litre)  is  roughly  equivalent  to  half  a  pint,  an  ordinary  tumblerful  or  breakfast- 
cupful  ;  and  that,  as  regards  solid  measures,  30  grammes  are  equivalent  to  a 
very  little  more  than  an  avoirdupois  ounce.] 

Menstruation. 

Menstruation  is  the  name  given  to  the  process  which  manifests 
itself  in  the  human  female  after  the  age  of  puberty  by  the  discharge 
from  the  genital  organs  at  regular  four-weekly  intervals  of  a  muco- 
sanguineous  secretion.  This  discharge  is  not  merely  the  result  of 
a  local  hyperaamic  condition,  but  is  the  expression  of  a  periodic 
excitation  of  the  entire  nervous  system  and  blood  vascular  system, 
intimately  related  with  the  whole  sexual  life  of  woman;  this  excita- 
tion is  itself  dependent  upon  the  process  of  ovulation,  an  incident  in 
the  series  of  manifestations  that  arise  from  the  periodic  undulatory 
movement  in  the  vital  processes  of  woman. 


THE  SEXUAL  EPOCH  OF  THE  MENARCHE.  129 

The  Mosaic  law  regarded  the  process  of  menstruation  as  unclean 
in  nature ;  the  menstruating  woman  was  unclean,  and  must  be  puri- 
fied in  a  prescribed  manner.  In  the  fifteenth  chapter  of  Leviticus, 
vv.  19-29,  we  read:  "And  if  a  woman  have  an  issue,  and  her 
issue  in  her  flesh  be  blood,  she  shall  be  put  apart  seven  days :  and 
whosoever  toucheth  her  shall  be  unclean  until  the  even.  *  *  * 
Every  bed  whereon  she  lieth  all  the  days  of  her  issue  shall  be  unto 
her  as  the  bed  of  her  separation.  *  *  *  But  if  she  be  cleansed 
of  her  issue,  then  she  shall  number  to  herself  seven  days,  and  after 
that  she  shall  be  clean.  And  on  the  eighth  day  she  shall  take  unto 
her  two  turtles,  or  two  young  pigeons,  and  bring  them  unto  the 
priest,  to  the  door  of  the  tabernacle  of  the  congregation." 

In  a  similar  manner  the  adherents  of  the  faith  of  Islam  regard 
a  menstruating  woman  as  unclean. 

This  view  is  found  also  in  the  earliest  medical  writings,  alike 
in  the  early  Indian  book  of  Susruta  and  in  the  later  writings  of 
Hippocrates,  and  it  persists  to  the  present  day  in  the  use  of  the 
expression  "  monthly  purification."  Susruta  teaches  that  in  India 
menstruation  begins  at  the  age  of  twelve,  and  recurs  monthly,  the 
flow  lasting  three  days.  In  the  Jewish  Talmud  it  is  asserted  (see 
"  La  Medecine  du  Talmud,"  by  Dr.  Rabbinowics)  that  menstruation 
begins  as  soon  as  the  girl  has  two  hairs  on  the  pubic  region,  or  at 
the  age  of  twelve,  even  in  the  absence  of  any  growth  of  the  pubic 
hair.  The  menstrual  blood  is  quite  peculiar  in  its  characters.  Thus, 
Raschi  relates,  the  mother  of  the  King  of  Persia  exhibited  sixty 
varieties  of  blood,  and  among  them  Rabba  was  able  to  detect  which 
was  the  menstrual  blood.  According  to  a  ra,bbinical  authority,  a 
woman  can  become  pregnant  as  soon  as  she  has  completed  her 
twelfth  year.  As  signs  of  puberty,  Rabbi  Josse  mentions  the  ap- 
pearance of  a  fold  beneath  the  nipple,  Rabbi  Akiba,  the  erection  of 
the  nipples,  Rabbi  d'Azai,  the  appearance  of  a  diark  areola  around 
the  nipples,  Rabbi  Josse,  the  recession  of  the  nipple  under  pressure 
followed  by  its  gradual  protrusion  when  the  pressure  is  removed, 
also  the  softening  of  the  mons  Veneris  (in  consequence  of  the  deposit 
of  fat  in  its  substance).  As  prodromal  signs  of  the  first  appearance 
of  menstruation,  the  Talmud  mentions,  pain  in  the  region  of  the 
umbilicus  and  in  the  uterus,  flatulence,  shivering,  white  flux,  heavi- 
ness in  the  head  and  the  limbs,  and  nausea. 

The  blood  discharged  during  menstruation  has  certain  peculiar 
properties.  It  is  always  fluid,  and  rarely  contains  fibrinous  clots, 
it  is  always  mixed  with  a  larger  or  smaller  quantity  of  mucus,  which 
gives  it  a  sticky  character;  the  reaction  is  alkaline,  the  smell  char- 
acteristic. Only  when  the  bleeding  is  very  profuse  are  coagulated 
masses  evacuated.  On  microscopical  examination  of  menstrual 


130  THE  SEXUAL  LIFE  OF  WOMAN. 

blood,  we  detect  erythrocytes  and  leucocytes,  the  proportional  num- 
ber of  the  latter  being  greater  than  in  pure  blood ;  there  is  an  ad- 
mixture also  of  epithelium  from  the  genital  mucous  membranes, 
cylindrical  cells  from  the  uterus,  flattened  cells  from  the  superficial 
layers  of  the  stratified  scaly  epithelium  of  the  vagina,  also  various 
micro-organisms  and  granular  detritus.  At  the  beginning  of  each 
menstruation,  the  admixture  of  mucus  is  greatest,  so  that  the  dis- 
charge sometimes  has  the  appearance  of  blood-stained  mucus;  but 
during  the  height  of  the  discharge  the  consistency  is  almost  that  of 
pure  blood.  The  quantity  of  blood  lost  at  each  period  is  said  to  vary 
from  90  to  240  grammes  (about  3  to  8  fluid  ounces)  ;  but  in  tropical 
climates  the  average  is  said  to  be  600  grammes  (20  ounces).  Ac- 
cording to  the  accurate  analysis  of  Denis,  menstrual  fluid  contains 
in  a  thousand  parts : 

Total  solid  constituents 175 . 00 

Comprising 

Fat 3.90 

Blood-corpuscles 64.40 

Albumin 48.30 

Extractives i .  10 

Salts 12. oo 

Mucus 45 . 30 


Water 825 .  oo 


Both  the  quality  and  the  quantity  of  the  blood  are  subject  to 
great  variations.  Thus,  for  instance,  Bouchardat  estimates  the  solid 
constituents  at  99.20  per  mille,  Vogel  at  161  per  mille,  and  Siino.i 
at  215  per  mille.  The  amount  of  blood  discharged  during  menstrua- 
tion depends  upon  the  temperament,  the  constitution,  and  the  oc- 
cupation, of  the  woman  concerned.  It  is  greater  in  vivacious 
brunettes  than  in  phlegmatic  blondes,  greater  in  southern  women 
than  in  those  dwelling  in  the  north,  greater  in  town  dwellers  than  in 
women  living  in  the  open  plains,  greater  in  those  whose  mode  of 
life  is  sedentary  than  in  those  engaged  in  some  active  occupation. 

Similar  considerations  apply  with  regard  to  the  duration  of  each 
period.  The  mean  duration  is  in  the  great  majority  of  cases  from 
four  to  five  days,  being  generally  the  same  in  successive  periods 
in  the  same  individual ;  in  exceptional  cases  the  flow  may  last  a 
week  or  more.  Menstruation  lasting  more  than  eight  days  must  be 
regarded  as  abnormal. 

Kricgcr  has  collected  data  relating  to  the  duration  of  the  individ- 
ual periods.  He  found  the  duration  constant  in  the  great  majority 
of  cases,  i.  e.,  93.285  per  cent. ;  but  variable  in  a  small  minority, 
i.  e.,  6.715  per  cent. 


THE  SEXUAL  EPOCH  OF  THE  MENARCHE.  131 

The  periods  in  which  the  duration  was  regular  did  not  always  last 
precisely  the  same  number  of  days,  the  duration  in  many  cases 
being  3  to  4  days,  5  to  6  days,  etc. ;  but  the  same  duration  recurred 
regularly  at  each  successive  period,  so  that  all  these  instances  must 
be  reckoned  among  the  periods  of  regular  duration.  The  duration 
must  be  regarded  as  irregular  or  variable  in  those  cases  in  which 
the  variation  was  from  2  to  4  days,  3  to  8  days,  etc.  Sometimes 
a  regular  three-day  or  five-day  period  becomes  transformed  into  an 
eight-day  period ;  or  conversely  an  eight-day  period  into  a  four-day 
period. 

Among  the  cases  in  which  the  duration  was  regular,  it  amounted 

Most  frequently  to  8  days,  in 26.695  Per  cent. 

Next  in  frequency  was  a  duration  of  3  days,  in 20.762  per  cent. 

Next,  a  duration  of  4  days,  in 16.949  per  cent. 

Next,  a  duration  of  5  days,  in n  .864  per  cent. 

L.  Mayer  has  also  drawn  a  distinction  between  constant  and 
variable  duration  of  the  menstrual  periods.  Among  4,927  women, 
he  found  4,542  (92.185$)  in  whom  the  duration  was  constant,  and 
385  (7.815$)  in  whom  it  was  variable.  Of  the  constant  periods, 
the  duration  was : 

8  days  in  1 182  women,  that  is  in 26.024  per  cent. 

4  days  in    829  women,  that  is  in 18.252  per  cent. 

3  days  in    731  women,  that  is  in 16.094  per  cent. 

5  days  in    730  women,  that  is  in 16.072  per  cent. 

An  extremely  short  duration,  less  than  24  hours,  was  found  in 
70  women,  an  extremely  long  duration,  7  to  14  days,  was  found  in 
175  women,  and  finally  a  duration  "exceeding  14  days  was  found  in 
19  women. 

The  mean  duration  in  these  cases  was  5.387  days. 

The  results  obtained  by  Szukiis,  who  investigated  the  duration  of 
the  periods  in  1,013  women,  are  somewhat  divergent  from  the  above. 
He  found: 

A  duration  of  a  few  hours  only  in  95  women,  that  is  in..  9.38  per  cent. 

A  duration  of  i  to  2  days  in 66  women,  that  is  in..  6.51  per  cent. 

A  duration  of  3  days  in 407  women,  that  is  in. .  40. 17  per  cent. 

A  duration  of  4  days  in  171  women,  that  is  in. .  16.88  per  cent. 

A  duration  of  5  to  6  days  in 115  women,  that  is  in..  11.35  Per  cent. 

A  duration  of  7  to  8  days  in 118  women,  that  is  in.  .  11.63  per  cent. 

A  duration  of  9  days  and  upwards  in  41  women,  that  is  in..  4.05  per  cent. 

The  mean  duration  in  these  cases  was  3.87  days. 
The  mean  duration  of  the  menstrual  flow  is: 

Tn  Paris 5       days. 

In  London 4.6  days. 

In  Berlin 4.5  days. 

In  Copenhagen 4.3  days  (according  to  Mayer,  5.3  days). 

In  Austria 3.8  days. 


132  THE  SEXUAL  LIFE  OF  WOMAN. 

The  interval  between  one  menstruation  and  the  next  (the  period 
that  elapses,  that  is  to  say,  between  the  commencement  of  one  period 
and  the  commencement  of  the  next)  is  in  the  great  majority  of 
cases  twenty-eight  days.  The  recurrence  in  many  women  is  extraor- 
dinarily exact,  not  merely  as  regards  the  day,  but  even  as  regards 
the  hour  of  the  day.  The  twenty-eight-day  type  of  menstruation  is 
found  in  about  70  per  cent,  of  the  cases ;  in  the  remainder,  the  thirty- 
day  type  is  most  frequent,  and  next  to  that  the  twenty-one-day  type. 
The  periodicity  of  menstruation  in  any  individual  may  however  be 
very  irregular. 

The  quantity  of  blood  lost  during  menstruation  varies  within  wide 
limits ;  according  to  approximate  estimates  the  usual  loss  at  a  single 
period. is  from  90  to  240  grammes  (about  3  to  8  fluid  ounces).  The 
following  summary  statement  is  made  by  Kriegcr  regarding  the 
quantity  lost  in  different  social  circumstances  and  in  various  na- 
tionalities : 

The  amount  of  blood  lost  and  the  duration  of  the  flow  are  less  in 
strong,  healthy  women,  leading  an  occupied,  active,  and  regular  life, 
especially  in  countrywomen  and  in  women  who  are  poor  and  chaste, 
than  it  is  in  delicate,  weakly  women,  leading  a  sedentary  life,  whose 
diet  is  abundant  and  stimulating,  and  who  are  accustomed  to  an 
ultra-luxurious  and  enervating  existence.  In  nuns,  for  example,  the 
quantity  of  the  menstrual  discharge  gradually  declines ;  shortly  after 
their  entrance  into  the  cloister,  various  irregularities  are  apt  to 
occur,  but  ultimately  the  flow  becomes  exceedingly  scanty  and  lasts 
for  a  single  day  only.  Climate  also  has  a  great  influence,  for  in  hot 
countries  women  usually  menstruate  very  abundantly,  whilst  in 
cold  countries  the  flow  is  scanty,  and  often  appears  only  in  the 
wanner  months  of  the  year.  Of  the  Lapp  and  Samoyede  women 
this  was  already  reported  by  Linnccn s  and  Virey.  Tilt  further  re- 
lates that  Eskimo  women  menstruate  only  during  the  summer 
months,  and  even  then  scantily. .  In  southern  France,  according  to 
Courty,  the  quantity  varies  from  120  to  240  grammes  (about  4  to 
8  ounces)  ;  but  it  may  rise  to  300,  350,  and  even  to  500  grammes 
(about  10,  12,  and  i6£  fluid  ounces).  In  the  tropics,  severe  menor- 
rhagia  is  said  to  be  common ;  and  the  fact  was  already  known  to 
Blumbenbach,  that  women  of  European  descent  born  in  the  tropics 
not  infrequently  succumb  to  haemorrhage  during  childbirth. 

L.  Mayer  has  endeavored  to  determine  the  relations  between  the 
quantity  and  the  quality  of  the  discharge,  and  distinguishes  the 
regular  composition,  when  a  considerable  quantity  of  dark-tinted, 
fluid  blood  is  passed,  from  the  irregular  composition,  when  a  small 
quantity  of  blood,  usually  pale  in  color,  is  passed,  or  an  excessive 
quantity  of  dark  blood,  often  coagulated,  or  a  discharge  of  varying 
composition. 


THE  SEXUAL  EPOCH  OF  THE  MENARCHE.  133 

Of  4,542  women  questioned  by  Mayer  in  regard  to  this  matter, 
there  were : 

2,998,  that  is  66.006  per  cent,  in  whom  the  composition  was  regular. 
1,544,  that  is  33.994  per  cent,  in  whom  the  composition  was  irregular. 

and  among  the  latter  the  discharge  was 

Scanty  and  for  the  most  part  pale  in  511;  that  is , ...   12.250  per  cent. 

Profuse  or  profuse  and  coagulated  in  838;  that  is 18.428  per  cent 

Variable  in 196 ;  that  is 4,315  per  cent. 

Investigation  regarding  the  individual  variations  that  occur  in 
this  respect  among  women,  showed  that  blondes  usually  menstruate 
more  profusely  than  brunettes,  and  that  in  the  former  also  the 
duration  of  the  individual  periods  is  longer. 

The  loss  of  blood  must  be  considered  less  in  respect  of  its  absolute 
quantity  than  in  respect  of  the  effect  which  continued  observation 
shows  its  loss  to  have  upon  the  organism.  If  the  loss  of  blood  con- 
tinues to  have  an  effect  after  the  flow  has  ceased,  if  a  woman  re- 
covers but  slowly,  or  even  fails  to  recover  fully  from  one  loss  before 
another  begins,  if  symptoms  of  increasing  anaemia  become  ap- 
parent, the  bleeding  must  be  regarded  as  a  pathological  perversion 
of  normal  menstruation.  Pathological  is  it  also  if  the  menstrual 
flow  does  not  exhibit  the  normal  slowly  rising  and  slowly  declining 
curve,  but  sets  in  profusely,  ceases  or  almost  ceases  for  a  time,  and 
then  again  suddenly  recurs.  In  some  cases  the  flow  is  not  profuse, 
but  lasts  for  a  long  time,  and  owing  to  this  long  duration  it  has  a 
debilitating  effect,  especially  in  anaemic  and  chlorotic  individuals. 

As  a  rule,  in  normal  menstruation,  the  admixture  of  the  alkaline 
cervical  mucus  suffices  to  keep  the  menstrual  discharge  fluid  and  to 
prevent  the  formation  of  fibrin.  On  the  other  hand,  the  discharge 
of  coagulated  masses  of  blood  will  alone  suffice  to  indicate  an  abnor- 
mally free  and  rapid  flow  of  blood. 

The  commonest  type  of  menstruation  is  the  more  or  less  regular 
recurrence  of  the  flow  at  intervals  of  twenty-eight  days.  Variations 
in  this  respect  are,  however,  very  frequent,  and  are  dependent  upon 
constitution,  position  in  life,  and  race.  In  general  it  may  be  said 
that  in  persons  of  strong  constitution,  the  type  of  menstruation  is 
much  more  regular,  than  in  persons  of  a  weakly,  delicate  constitu- 
tion ;  that  in  vivacious,  ardent  natures  the  menses  more  readily 
anticipate  the  expected  period  of  their  return,  whereas  in  those  of 
a  flaccid,  lymphatic  temperament  a  retardation  is  more  likely  to 
occur ;  and  that  amongst  women  of  the  upper  classes  of  society  the 
type  of  menstruation  is  far  more  frequently  irregular  than  amongst 
women  of  the  working  classes  and  amongst  countrywomen. 
Whereas  in  many  women  the  regularity  of  the  menstrual  rhythm 


134  THE  SEXUAL  LIFE  OF  WOMAN. 

is  so  precise  that  the  flow  recurs,  not  merely  at  regular  intervals  of 
twenty-eight  days,  but  even  time  after  time  at  exactly  the  same 
hour  of  the  day  —  in  other  cases  the  interval  between  two  periods 
may  vary  from  twenty-one  to  thirty  days. 

L.  Mayer,  who  made  observations  on  the  type  of  menstruation 
in  5,671  women,  and  tabulated  his  results,  distinguishes  between 
constant  and  inconstant  intervals.  Among  the  constant  intervals  he 
enumerates,  those  forms,  both  regular  and  irregular,  which  do  not 
during  the  whole  life  of  the  individual  undergo  transformation  into 
another  form,  but  remain  always  of  the  same  type.  If,  for  instance, 
in  any  individual  the  interval  is  always  either  two  or  eight  weeks,  in 
that  woman  menstruation  is  indeed  irregular,  but  constant  in  type. 
If,  however,  for  some  years  she  menstruates  at  intervals  either  of  two 
or  of  eight  weeks,  and  then  proceeds  to  menstruate  at  intervals  of 
four  weeks,  her  menstruation  is  of  the  inconstant  type.  Mayer 
found  among  his  5,671  cases 

The  constant  type  in  4,981  women,  that  is  in 87.83  per  cent. 

The  inconstant  type  in  690  women,  that  is  in 12.16  per  cent 


Of  the  cases  in  which  the  type  was  constant  there  were  69.68 
per  cent,  in  which  the  regular  period  of  four  weeks  obtained,  and 
20.31  per  cent,  in  which  it  was  irregular  in  the  sense  above  defined. 
Among  these  latter,  the  commonest  periods  were  15  to  21  days  and 
22  to  27  days.  The  same  author  observed  the  irregular  type  of 
menstruation  in  nearly  one-fourth  of  the  women  belonging  to  the 
well-to-do  classes. 

According  to  the  observations  of  Krieger  on  481  cases  in  which 
the  periods  were  regular,  that  is,  in  which  the  intervals  in  each  case 
were  equal  in  duration,  the  time  from  the  commencement  of  one 
period  to  the  commencement  of  the  next  was: 

28  days  in 70.80  per  cent. 

30  days  in 13-74  per  cent. 

21  days  in 1.66  per  cent. 

27  days  in 1 .45  per  cent. 

As  regards  the  season  in  which  menstruation  first  appears,  Krieger 
states  that  in  one-half  of  the  women  examined  by  him  menstrua- 
tion had  begun  in  the  autumn  season,  in  the  month  of  September, 
October,  or  November. 

Szukits,  as  a  result  of  an  investigation  into  the  menstrual  func- 
tions of  Austrian  women,  determined  that  among  1,013  women  men- 
struation occurred : 

Every  28  to  30  days  in 642  women. 

Every    8  to  21  days  in. 169  women. 

Every  35  to  56  days  in 128  women. 

And  was  quite  irregular  in 74  women. 


THE  SEXUAL  EPOCH  OF  THE  MENARCHE.  135 

In  500  Jewish  women,  Hirsch  found  that  menstruation  occurred : 

23  days  after  the  beginning  of  the  last  menstruation  in. 19 

24  days  after  the  beginning  of  the  last  menstruation  in 29 

25  days  after  the  beginning  of  the  last  menstruation  in 36 

26  days  after  the  beginning  of  the  last  menstruation  in 56 

27  days  after  the  beginning  of  the  last  menstruation  in 62 

28  days  after  the  beginning  of  the  last  menstruation  in 73 

275 


and  in  the  remaining  cases  at  other  intervals  than  those  stated.  He 
is,  therefore,  of  opinion  that  in  the  majority  of  Jewish  women  the 
type  of  menstruation  is  shorter  then  twenty-nine  days. 

According  to  Brierre  de  Boismont,  among  100  women  menstrua- 
tion recurred : 

Every  4  weeks  in ' 61  women. 

Every  3  weeks  in •. 28  women. 

Every  2  weeks  in I  woman. 

And  at  various  irregular  periods  in 10  women. 

Tilt  found  among  100  women  that  menstruation  recurred: 

Every  4  weeks  in 77  women. 

Every  3  weeks  in 17  women. 

Every  2  weeks  in -. I  woman. 

Every  6  weeks  in 5  women. 

Foster  instituted  inquiries  regarding  this  matter  in  56  healthy 
women.  In  380  periods,  45  recurred  after  an  interval  of  28  days, 
225  after  a  shorter  interval  than  this,  no  after  a  longer  interval. 
The  duration  of  the  flow  varied  from  I  to  14  days ;  most  commonly 
it  lasted  from  3  to  5  days. 

A  peculiar  change  in  the  type  of  menstruation  sometimes  mani- 
fests it.self  in  this  way,  that  in  women  in  whom  the  regular  four- 
weekly  type  of  menstruation  has  prevailed,  exactly  in  the  middle 
of  this  four-weekly  period  the  menstrual  molimina,  with  or  without 
menstrual  discharge,  make  their  appearance ;  the  patient  suffers 
from  pain  in  the  lower  belly,  sacrache,  sensation  of  weight,  and 
bearing-down  pains.  Conrty,  Dubois,  and  Pa-jot  Ncgrier  have  de- 
scribed such  cases  of  molimcn  ntcrin  intermenstruel,  which  Tilt 
denotes  by  the  term  remittent  menstruation. 

From  the  earliest  times  the  process  of  menstruation  has  attracted 
the  attention  of  natural  philosophers,  and  has  led  them  to  formulate 
hypotheses  and  to  institute  investigations,  especially  in  order  to 
ascertain  whether  the  connection  between  ovulation  and  menstrua- 
tion is  one  of  temporal  succession  merely,  or  whether  the  relation 
is  a  causal  one. 

From  Hippocrates  and  Galen  downwards  until  well  beyond  the 
middle  ages,  the  view  of  the  father  of  medicine  was  generally  ac- 


136  THE  SEXUAL  LIFE  OF  WOMAN. 

cepted,  that  menstruation  is  a  purificatory  process  by  means  of  which 
materials  harmful  to  the  organism  are  eliminated  from  the  body  — 
a  view  which  finds  expression  also  in  the  religious  and  legal  ordi- 
nances of  all  times. 

A  new  epoch  of  scientific  research  into  the  nature  of  menstruation 
began  with  de  Graaf's  discovery  of  the  ovarian  follicles  (1672). 
This  discovery  did  not,  indeed,  bring  ovulation  and  menstruation 
into  immediate  relationship,  but  it  certainly  paved  the  way  for  the 
opinion  expressed  by  Sintcmma,  a  countryman  of  de  Graaf,  that  the 
ova,  even  in  virgins,  leave  the  ovary  spontaneously,  and  by  their 
contact  with  the  capillary  terminations  of  the  blood-vessels  give 
rise  to  the  menstrual  bleeding  (1728). 

As  a  result  of  anatomical  investigations,  Negrier,  in  1840,  was 
the  first  to  establish  the  thesis  that  in  women  suffering  from  con- 
genital absence  of  the  ovaries,  menstruation  never  occurs ;  that  after 
the  loss  of  the  ovaries,  menstruation  always  ceases;  that  during 
pregnancy  and  lactation  and  during  the  climacteric  period,  ovulation 
ceases ;  and  that  a  relation  of  temporal  succession  obtains  between 
ovulation  and  menstruation.  This  close  relation  between  the  two 
processes  was  maintained  also  by  Gendrin  at  about  the  same  date. 
Later,  Gird'n.'ood,  by  post-mortem  research,  proved  that  the  number 
of  scars  in  the  ovary  coincides  with  the  number  of  previous  men- 
struations. 

Brierre  de  Boismont,  in  his  exhaustive  work  on  Menstruation, 
lays  stress  on  the  view  that  the  periodically  recurring  ovulation 
furnishes  the  impulse  for  the  menstrual  flow.  First  among  German 
investigators,  Bischoff  upheld  the  opinion  that  maturation  and  dis- 
charge of  ova  are  spontaneous  processes  occurring  independently 
of  sexual  intercourse,  and  compared  heat  or  rut  in  other  animals 
to  menstruation  in  women  —  a  view  shared  by  Ponchet  and  Coste. 
Ovulation  occurs  simultaneously  with  the  menstrual  flow,  and  the 
follicles  burst  toward  the  end  of  menstruation. 

Pfiilger,  in  his  important  work  on  the  significance  and  cause  of 
menstruation,  has  demonstrated  the  causal  connection  between  men- 
struation and  ovulation.  The  bleeding  and  the  discharge  of  the 
ova  are  according  to  him  joint  effects  of  a  common  cause.  It  is 
not  the  bursting  of  the  follicle,  but  the  ripening  of  the  follicle,  that 
gives  rise  to  the  menstrual  congestion.  The  pressure  of  the  growing 
follicle  on  the  surrounding  ovarian  tissue  gives  rise  to  a  continued 
stimulation  of  the  ovarian  nerves;  the  summation  of  these  stimuli, 
which  after  the  lapse  of  a  certain  time  attain  always  a  certain  de- 
gree of  intensity,  results  in  a  reflex  from  the  spinal  cord  taking  the 
form  of  great  congestion  of  the  genital  organs ;  this  congestion  leads, 
on  the  one  hand,  to  haemorrhage  from  the  uterine  mucous  membrane, 


THE  SEXUAL  EPOCH  OF  THE  MENARCHE.  .  137 

and,  on  the  other  hand,  and  as  a  rule  simultaneously,  to  the  burst- 
ing of  the  ovarian  follicle.  The  swelling  and  granulation  of  the 
uterine  mucous  membrane  at  every  menstrual  period  signifies  noth- 
ing else  than  the  commencement  of  the  formation  of  the  decidua. 

N'dgele  already  mentioned  the  view,  that  inasmuch  as  immediately 
after  the  first  appearance  of  menstruation  a  woman  has  become 
capable  of  reproducing  the  species,  each  process  of  menstruation 
must  be  regarded  as  a  renewal  of  the  exhausted  faculty  for  con- 
ception. 

Pniiger's  teaching  has  been  opposed  by  Sigismund,  who,  whilst 
admitting  the  periodicity  of  ovulation  and  menstruation,  yet  re- 
gards the  two  processes,  in  the  uterus  the  formation  of  the  men- 
strual decidua,  in  the  ovary  the  rupture  of  the  graafian  follicle,  as 
independent  of  one  another,  even  though  they  occur  simultaneously. 
Should  fertilization  occur,  the  ovum  implants  itself  in  the  prepared 
soil ;  should  fertilization  fail  to  occur,  the  menstrual  haemorrhage 
ensues.  Thus,  the  occurrence  of  menstruation  indicates  that  fertili- 
zation of  the  ovum  has  failed  to*  occur.  On  this  theory,  then,  the 
ovum  that  is  fertilized  belongs  to  the  first  period  missed,  whereas 
Pfliiger  assumes  that  when  pregnancy  occurs,  it  is  always  the  ovum 
belonging  to  the  time  of  the  previous  menstruation  —  the  last 
actual  menstrual  discharge  —  that  is  fertilized. 

Lowenhardt,  in  his  work  on  the  Diagnosis  and  Duration  of  Preg- 
nancy, advances  the  same  views  as  Sigismund.  The  fertilized  ovum, 
in  his  opinion  also,  is  that  of  the  first  period  missed ;  and  since  at 
the  time  at  which  he  believes  fertilization  to  occur  the  ovum  is 
certainly  still  in  the  ovary,  fertilization,  on  this  theory,  must  always 
take  place  in  the  ovary  itself,  and  the  fertilized  ovum  cannot  begin 
its  intra-uterine  life  till  a  month  has  elapsed  after  fertilization. 
Reichert,  Kundrat,  Engelmann,  and  Williams,  basing  their  views 
on  anatomical  data,  are  of  opinion  that  ovulation  recurs  periodically, 
and  that  the  extrusion  of  the  ovum  occurs  not  before  but  after  the 
commencement  of  menstruation. 

According  to  Hcnsen,  the  observed  facts  support  the  view  that 
the  follicles  burst  as  a  rule  toward  the  end  of  menstruation ;  antici- 
pation or  postponement  of  the  opening  of  the  follicle  (conception 
before  or  after  menstruation)  would,  however,  appear  not  to  be 
impossible. 

Leopold,  who  assumes  that  menstruation  may  occur  without  ovu- 
lation and  ovulation  without  menstruation,  maintains  on  anatomical 
grounds  that  the  rupture  of  the  graafian  follicle  occurs  chiefly  dur- 
ing menstruation,  under  the  influence  of  the  swelling  due  to 
menstrual  congestion.  Menstruation  with  ovulation  he  believes  to 
be  a  common  occurrence,  menstruation  without  ovulation,  an  un- 


138  THE  SEXUAL  LIFE  OF 

usual  occurence.  Further,  it  is  certain  that,  at  the  time  when  the 
periodic  bleeding  is  due,  ovulation  may  occur,  even  though  the 
menstrual  discharge  fails  to  make  its  appearance  (ovulation  without 
menstruation). 

C Hasan  and  Glareke  also  adhere  to  the  generally  accepted  view 
that  ovulation  is  a  periodic  process,  usually  but  not  necessarily 
synchronous  with  menstruation. 

Strassman  bases  on  clinical  facts  and  on  experiments  the  follow- 
ing view  of  flie  connection  between  ovulation  and  menstruation. 
The  principal  processes  in  the  organism  of  the  sexually  mature 
woman  run  their  course  in  a  periodic  rhythm  resembling  an  undula- 
tory  movement,  the  acme  of  which  occurs  in  the  antemenstrual 
period  with  the  aim  of  preparing  for  the  development  of  an  in- 
fantile organism.  Whilst  an  ovum  is  maturing  in  the  ovary,  in  the 
uterus,  in  dependence  upon  this  maturation,  the  antemenstrual 
mucous  membrane,  fitted  for  the  reception  and  nutrition  of  the 
fertilized  ovum,  is  also  undergoing  development.  At  the  acme  of 
the  undulatory  movement,  the  graafian  follicle  ruptures  and  the 
ovum  is  liberated,  to  undergo  fertilization  in  the  infundibulum  of 
the  Fallopian  tube.  If  fertilization  fails  to  occur,  or  if  for  any 
reason  the  graafian  follicle  fails  to  rupture,  then,  in  consequence  of 
and  at  the  time  of  the  highest  intra-ovarian  tension,  at  the  time,  when 
the  rupture  of  the  follicle  usually  occurs,  the  extrusion  of  blood  from 
the  capillaries  of  the  uterine  mucous  membrane  begins.  The  inter- 
mediation between  the  ovary  and  the  uterus  is  probably  effected  by 
means  of  the  sympathetic  ganglion  in  the  ovary  discovered  by 
Elizabeth  Wintcrhaltcr,  and  effected  in  this  manner,  that  the  stimu- 
lus proceeding  from  the  ripening  follicle  passes  along  the  nerve- 
fibrils  surrounding  the  follicle  to  the  processes  of  the  nerve  cells 
of  this  sympathetic  ganglion,  accumulating  in  these  cells  till  a  cer- 
tain degree  of  intensity  has  been  reached,  and  then,  by  means  of 
other  processes  and  of  the  vasomotor  nerves,  influencing  the  vessels 
of  the  uterus. 

Gcbhard  likewise  believes  menstruation  to  be  dependent  on  the 
ovarian  function,  and  thinks  that  it  is  probably  brought  about  in  a 
reflex  manner  by  the  gradual  growth  of  the  ovarian  follicles.  It 
appears  that  most  commonly  at  the  time  of  menstruation  a  graafian 
follicle  ripe  to  bursting  is  to  be  found  in  the  ovary,  but  to  this  rule 
there  are  many  exceptions.  We  cannot  exclude  the  possibility,  that 
the  ovum  from  a  follicle  that  burst  after  the  commencement  of  the 
menstrual  flow  may  be  fertilized ;  but  more  commonly  the  ovum 
that  is  fertilize^  is  that  of  the  first  period  missed.  The  sudden 
decline  in  vital  energy  that  occurs  just  before  menstruation  is  ex- 
plained by  Gebhard  as  a  kind  of  atavism,  dependent  on  the  fact 


THE  SEXUAL  EPOCH  OF  THE  MENARCHE.  139 

that  many  of  the  lower  animals,  butterflies,  for  instance,  succumb 
as  soon  as  they  have  fulfilled  their  duty  of  reproducing  the  species. 

A  number  of  modern  investigators,  however,  deny  that  any  re- 
lation, temporal  or  causal,  exists  between  ovulation  and  menstrua- 
tion, and  affirm  that  the  latter  process  is  quite  independent  of  the 
former. 

Thus,  Christopher  Martin  maintains  that  a  special  menstrual 
centre  exists  in  the  lumbar  portion  of  the  spinal  cord,  the  impulses 
from  which  proceed  to  the  uterus  by  way  of  the  splanchnic  plexus, 
the  ovarian  plexus,  or  perhaps  by  both.  Similar  views  are  held  by 
La^(.1son  Tait,  Collins,  and  Johnstone,  who  severally  maintain  that 
the  ovaries  are  no  more  concerned  in  the  production  of  menstrua- 
tion than  any  other  organ  of  the  body  —  the  liver,  for  instance. 
They  direct  attention  to  the  periodicity  that  occurs  in  the  functional 
activity  of  various  other  organs,  in  respiratory  and  cardiac  activity, 
for  instance,  both  of  which  undergo  rhythmical  changes  as  a  re- 
sult of  nervous  influences.  The  cessation  of  menstruation  after 
oophorectomy  they  attribute,  not  to  the  cessation  of  ovulation,  but 
to  the  division  of  the  nerves  which  run  across  .the  broad  ligaments 
of  the  uterus  and  upon  which  menstruation  depends.  Heat  and 
rut  in  animals  have  a  different  significance  from  menstruation.  The 
latter  process  is  induced  by  civilization  and  by  the  adoption  of  the 
upright  posture. 

But,  taking  all  this  into  consideration,  we  must  hold  fast  to  the 
fundamental  principles,  that  ovulation  occurs  at  that  period  of  life, 
and  only  at  that  period,  during  which  menstruation  proceeds  regu- 
larly;  that  ovulation  begins  when  externally  and  in  the  whole  de- 
velopment of  the  girl  the  signs  of  sexual  maturity  manifest  them- 
selves ;  and  that  ovulation  ceases  at  the  climacteric,  when  menstrua- 
tion also  ceases.  We  must  regard  as  rare  exceptions  to  this  rule 
cases  in  which  ovulation  begins  before  the  nrenarche  and  persists 
after  the  menopause. 

A  physiological  interruption  of  menstruation  occurs  during  preg- 
nancy and  lactation ;  it  seems  improbable,  however,  that  during  this 
interval  ovulation  also  is  in  abeyance.  It  is  established  by  anatomi- 
cal investigations  that  ovulation  and  menstruation  commonly  occur 
in  association ;  but  that  menstruation  sometimes,  though  rarely,  oc- 
curs in  the  absence  of  ovulation ;  and,  finally,  that  intermenstrual 
ovulation  is  also  a  rare  occurrence.  In  the  majority  of  cases,  either 
just  before  or  just  after  the  commencement  of  the  menstrual  flow, 
rupture  of  a  graafian  follicle  occurs.  After  complete  oophorectomy, 
menstruation  ceases ;  it  is  only  when  functionally  active  portions 
of  ovarian  tissue  have  been  left  behind,  that  menstruation  continues 
to  occur.  In  the  absence  of  the  ovaries,  the  menstrual  function  is 


140  THE  SEXUAL  LIFE  OF  WOMAN. 

in  abeyance;  hence,  for  the  performance  of  that  function,  the 
presence  of  ripening  ovarian  follicles  and  of  other  follicles  capable 
of  ripening  later,  is  an  indispensable  requisite. 

A  certain  analogy  between  heat  and  rut  in  animals  and  menstrua- 
tion in  women  may,  according  to  the  investigations  of  Bischoff, 
Hcgar,  Strassmann,  and  others,  certainly  be  maintained.  Heat 
or  rut  is  a  process  occurring  in  mammals,  dependent  on  the  repro- 
ductive glands,  characterized  by  an  increase  in  sexual  and  general 
excitability,  with  congestion  of  the  pudendum  and  the  vagina, 
swelling  of  the  sebaceous  glands  of  the  external  genitals,  and  in- 
creased secretion ;  from  the  vulval  cleft  there  flows  a  peculiar,  strong- 
smelling  mucus,  often  tinted  red  from  admixture  with  blood ;  there 
is  frequent  micturition,  the  uterine  glands  are  swollen,  the  Fallopian 
tubes  are  also  swollen,  and  are  soft  and  erected.  A  well-developed 
menstrual  bleeding,  analogous  to  that  which  occurs  in  the  human 
species,  occurs,  among  the  lower  animals,  only  in  apes.  Matura- 
tion of  ova  precedes  the  period  of  heat,  and  rupture  of  the  graafian 
follicle  occurs  during  that  period. 

Heat  or  rut  occurs  in  animals  at  certain  seasons  of  the  year, 
which  may,  according  to  the  species  and  the  mode  of  life  of  the 
animal  concerned,  be  in  spring,  summer,  autumn,  or  winter.  The 
season  of  heat  or  rut  hac  further  several  periods  of  heat,  each 
lasting  several  days,  and  among  domesticated  animals,  mares,  cows, 
and  bitches,  succeeding  one  another  at  intervals  of  three  or  four 
weeks ;  in  wild  animals,  rut  occurs  once  only  in  the  year.  In  ani- 
mals, sexual  intercourse  takes  place  during  the  time  of  the  menstrual 
discharge,  and  during  this  time  also  the  capacity  for  conception  is 
increased ;  in  the  absence  of  heat,  the  genital  organs  are  in  a  more 
quiescent  condition.  In  this  connection,  the  experiments  on  ani- 
mals made  by  Strassniann,  with  a  view  to  determining  the  influ- 
ence upon  the  uterus  of  rise  of  pressure  in  the  ovary,  are  of  great 
interest;  these  experiments  showed  that  a  rise  of  intra-ovarian 
pressure,  produced  by  the  injection  of  fluid  into  the  parenchyma 
of  the  ovary,  led  to  changes  in  the  endometrium  and  the  external 
genital  organs  corresponding  to  .those  occurring  in  an  animal  on 
heat. 

In  the  human  species,  however,  in  contradistinction  to  what  oc- 
curs in  the  lower  animals,  there  is  a  certain  disinclination,  on  the 
part  of  the  male  at  any  rate,  to  sexual  intercourse  during  menstrua- 
tion. The  human  female  moreover,  notwithstanding  the  periodicity 
of  her  sexual  life,  is  at  all  times  capable  of  conception;  this  capabil- 
ity is  not  confined  to  any  particular  part  of  the  intermenstrual  period, 
for  conception  may  occur  at  any  time  during  that  period,  and  has 
even  been  known  to  result  from  intercourse  during  menstruation. 


THE  SEXUAL  EPOCH  OF  THE  MENARCHE.  141 

This  peculiar  characteristic  of  the  human  reproductive  capacity  has 
been  regarded  as  compensatory,  furnished  by  nature  in  her  continual 
endeavour  for  the  perpetuation  of  the  species,  to  counteract  the  re- 
stricting influences  imposed  by  civilization  on  the  normal  process 
of  reproduction. 

Credible  observations  even  exist,  indicating  that  among  many 
primitive  peoples,  in  whom  at  the  time  of  puberty  no  social  laws 
hinder  the  limitless  exercise  of  the  reproductive  functions,  this 
capacity  on  the  part  of  woman  to  conceive  at  any  time  has  no 
existence,  and  that  the  reproductive  capacity  of  such  human  beings 
is,  like  that  of  the  lower  animals,  confined  to  a  certain  season  of 
the  year.  Thus.  G.  Schlesingcr  reports  of  the  Ainus  of  the  island 
of  Yezo,  "  A  friend  of  mine  in  Sapporo  believes  himself  to  have 
observed  that  the  Ainus  have  a  certain  definite  rutting  period,  and 
that  in  them,  as  in  many  of  the  lower  animals,  the  process  of  re- 
producing the  species  occurs  only  at  a  certain  season  of  the  year." 
An  identical  statement  is  current  concerning  the  Indians  of  West- 
ern America. 

The  mucous  membrane  of  the  uterus  undergoes  during  menstrua- 
tion important  changes,  and  a  question  much  disputed  is,  whether 
in  the  course  of  menstruation  the  whole  of  the  uterine  mucous 
membrane  is  removed,  or  a  part  only,  whether  it  is  shed  in  its  entire 
thickness,  or  is  at  least  deprived  of  its  epithelium.  According  to 
the  observations  made  by  Leopold  on  dead  bodies,  the  mucous  mem- 
brane of  the  uterus  becomes  swollen  shortly  before  the  commence- 
ment of  the  menstrual  discharge,  until,  partly  in  consequence  of 
cellular  proliferation,  partly  in  consequence  of  oedematous  infiltra- 
tion, and  partly  in  consequence  of  enlargement  of  the  lymph-spaces, 
it  attains  a  thickness  of  6  to  7  millimetres  (£  of  an  inch).  The 
superficial  capillaries  are  notably  enlarged,  and  an  effusion  of  blood- 
elements  continues  for  several  days,  without  the  occurrence  of  any 
fatty  degeneration  in  the  tissues.  The  epithelium  and  the  most 
superficial  cell-layers  of  the  mucous  membrane  are,  however,  under- 
mined and  shed.  No  complete  destruction  of  the  mucous  membrane 
occurs,  however,  and  fatty  degeneration  forms  no  part  of  the  men- 
strual process  as  such. 

Moricke,  who  examined  portions  of  the  uterine  mucous  mem- 
brane removed  with  the  curette  during  menstruation  from  living 
women,  found  the  superficial  layers  of  the  mucous  membrane  to 
be  intact,  and  he  regards  the  shedding  of  the  epithelium  described 
by  other  authorities  as  cadaveric  phenomenon.  Sinety,  who  also 
found  the  uterine  mucous  membrane  intact  during  menstruation, 
adheres  to  the  same  view. 

Von  Kahlden  concludes,  as  a  result  of  investigations  made  post- 


142  THE  SEXUAL  LIFE  OF  WOMAN. 

mortem,  that  during  menstruation  the  greater  part  of  the  mucous 
membrane,  not  the  superficial  epithelium  only,  but  the  stroma  itself 
down  to  its  deepest  layers,  is  shed.  According  to  von  Tasscnbroek 
and  Mendes  le  Leon,  however,  the  most  superficial  layers  only  are 
shed  during  menstruation. 

According  to  Westphden,  whose  investigations  were  made,  partly 
on  masses  removed  by  the  curette,  and  partly  on  freshly  extirpated 
uteri,  a  sanguineo-serous  infiltration  of  the  mucous  membrane  begins 
about  ten  days  before  menstruation.  Great  vascular  dilatation  oc- 
curs only  just  before  menstruation.  The  uterine  glands  undergo 
enlargement,  and  during  and  immediately  after  the  flow,  numerous 
shed  epithelium  cells  occupy  the  lumen  of  the  glands.  For  the  rest, 
however,  in  the  interior  of  the  uterus  shortly  after  menstruation, 
we  find  an  almost  continuous  epithelial  covering.  Some  days  after 
menstruation,  the  proper  regeneration  of  the  mucous  membrane 
occurs. 

Mandl,  who  examined  totally  extirpated  uteri,  asserts  that  during 
menstruation  the  epithelial  covering  of  the  mucous  membrane  is 
never  completely  lost,  but  that  just  as  little  does  it  remain  com- 
pletely intact.  The  regeneration  of  the  lost  areas  of  epithelium  pro- 
ceeds even  during  menstruation. 

The  researches  of  Kundrat  and  Engelmann  on  uteri  obtained  post- 
mortem led  these  authors  to  describe  as  follows  the  anatomical 
changes  that  occur  in  the  uterine  mucous  membrane  at  the  time 
of  the  catamenial  haemorrhage.  In  the  premenstrual  epoch  a  round- 
cell  infiltration  occurs  in  the  interglandular  tissue,  the  lumina  of 
the  uterine  glands  become  enlarged,  and  the  blood-vessels  dilated ; 
subsequently,  fatty  degeneration  of  the  superficial  epithelium  and 
the  epithelium  of  the  glands  occurs,  leading  to  laceration  of  the 
vessels  and  destruction  of  the  affected  area  of  tissue ;  after  the 
cessation  of  the  bleeding,  regeneration  of  the  mucous  membrane 
occurs. 

According  to  Gebhard,  three  stages  may  be  distinguished.  The 
first  stage  is  that  of  premenstrual  congestion,  or  stage  of  engorge- 
ment :  the  capillary  vessels  of  the  mucous  membrane  become  dis- 
tended with  blood,  the  membrane  itself  becomes  softened,  the  meshes 
of  the  stroma  become  enlarged  and  are  filled  with  the  morphological 
constituents  of  the  blood,  subepithelial  hsematomata  are  formed. 
The  second  stage  is  that  in  which  the  blood  finds  its  way  to  the  ex- 
terior :  owing  to  the  turgescence  of  the  mucous  membrane  the  blood 
is  able  to  exude  between  the  cells  of  the  intact  epithelium ;  further, 
tne  epithelium  becomes  lacerated  in  various  places  where  hremato- 
mata  have  formed  beneath  it,  allowing  the  blood  to  exude  through 
the  apertures  thus  formed;  shreds  of  epithelium  may  be  washed 


THE  SEXUAL  EPOCH  OF  THE  MENARCHE.  143 

away  by  the  blood-stream.  The  third  stage  is  that  of  post-menstrual 
regeneration :  the  swelling  of  the  mucous  membrane  disappears,  the 
detached  areas  of  epithelium  readhere,  the  blood  effused  into  the 
interstices  of  the  tissue  is  reabsorbed,  or  is  in  part  transformed 
into  yellowish-brown  flakes  of  pigment.  According  to  Gebhard's 
view,  during  menstruation  destruction  of  the  uterine  mucous  mem- 
brane does  not  "occur.  At  no  time  is  the  membrane  denuded  of 
large  areas  of  epithelium ;  a  very  active  process  of  regeneration  oc- 
curs, however,  in  the  superficial  epithelium  and  the  epithelium  of 
the  glands,  which  fits  the  uterine  mucosa  for  the  reception  of  the 
fertilized  ovum  by  keeping  it  in  an  ever-young  and  renovated  con- 
dition. The  mucous  membrane  of  the  cervix  takes  part  in  men- 
struation at  most  by  an  increased  secretion  of  mucus. 

According  to  Landau  and  Rhcinstein,  the  mucous  membrane  of 
the  Fallopian  tubes  contributes  to  the  menstrual  haemorrhage  ;  Fritsch 
and  Strassmann,  however,  are  opposed  to  the  view  that  there  is  a 
regular  tubal  menstruation. 

Pathology  of  Menstruation. 

Only  a  small  proportion  of  girls  and  women  are  entirely  free, 
at  the  time  of  menstruation,  from  all  change  both  in  their  bodily 
and  in  their  mental  state.  A  very  great  majority  complain  of  feel- 
ing more  or  less  unwell,  of  sensations  of  weight  and  pressure  in 
the  hypogastric  region,  of  a  general  feeling  of  languor,  loss  of 
appetite,  headache,  irritability,  sometimes  of  an  inclination  to  weep ; 
in  women,  a  change  in  the  intensity  of  the  sexual  impulse  mani- 
fests itself,  an  increase  in  some,  a  decrease  in  others. 

Not  infrequently  during  menstruation,  the  cardiac  activity  is 
notably  affected,  so  that,  regularly  at  the  commencement  of  each 
period,  disagreeable  sensations  occur  in  the  cardiac  region,  with 
increased  frequency  of  the  heart's  action ;  or  complaint  is  made 
of  coldness  and  dampness  of  the  hands,  of  icy  coldness  of  the  feet, 
which  feel  as  if  "  dead  "  to  half  way  up  the  calves,  and  cannot  be 
warmed  — •  phenomena  which,  in  the  cases  under  consideration, 
occur  only  at  the  time  of  menstruation,  and  are  to  be  regarded  as 
manifestations  of  the  menstrual  reflex. 

I  examined  140  women  in  whom  the  heart  and  the  vascular  sys- 
tem were  normal,  during  a  number  of  successive  menstrual  periods, 
and  in  12  of  these  women,  either  at  the  commencement  or  during 
the  course  of  the  flow,  I  observed  an  increase  in  the  frequency  of 
the  heart  to  the  extent  of  from  12  to  28  beats  per  minute;  in  young 
girls,  a  systolic  murmvir  was  sometimes  audible  during  menstrua- 
tion, but  was  inaudible  in  the  intermenstrual  intervals.  In  all  these 
persons,  menstruation  was  regular ;  there  was  no  abnormality  in  re- 


144  THE  SEXUAL  LIFE  OF  WOMAN. 

spect  either  of  the  duration  or  of  the  quantity  of  the  flow.  The 
heart  in  these  cases  was,  therefore,  affected  by  the  normal  menstrual 
process. 

A  remarkable  illustration  of  the  alleged  influence  of  menstrual  dis- 
turbances on  the  pulse  is  reported  by  de  Villeneuve,  who  states 
that  Chinese  physicians,  being  accustomed  to  feel  the  pulse  in 
many  different  arteries,  are  able,  by  a  comparison  o"f  the  characters 
of  the  pulse  in  the  two  arms,  to  determine  whether  a  woman  men- 
struates regularly  or  irregularly. 

Many  women  and  girls  show  well-marked  menstrual  molimina, 
uneasy  or  actually  painful  local  sensations  in  the  genital  organs, 
sacrache,  painful  uterine  contractions,  and  disturbances  of  the 
general  constitutional  state,  which  are  dependent  upon  menstrual 
congestion  of  the  pelvic  organs,  upon  local  engorgement ;  sometimes 
such  symptoms  are  the  result  of  uterine  contractions  caused  by 
hypersemia  of  the  uterus,  and  these  cases  often  take  a  paroxysmal 
form. 

Important  disturbances  of  the  general  constitutional  state  result 
from  sudden  suppression  of  the  normal  menstrual  flow,  such  as 
may  be  the  effect  of  a  severe  chill,  of  sudden  mental  impressions, 
even  of  errors  in  diet  or  the  use  of  certain  drugs,  and  may  some- 
times follow  artificial  withdrawal  of  blood. 

In  many  women,  a  few  days  or  it  may  be  a  few  hours  only  be- 
fore every  menstruation,  changing  manifestations  of  manifold  dis- 
orders may  recur.  Among  these  may  be  mentioned,  general  ex- 
citement of  the  nervous  system,  notable  alteration  in  the  voice, 
strong  inclination  to  sadness,  tearfulness,  erotic  longings,  great  ir- 
ritability and  sensitiveness  of  the  sensory  system,  drowsiness,  flush- 
ings of  the  face,  giddiness,  swooning.  The  appetite  is  impaired, 
the  breath  has  a  disagreeable  smell,  the  digestion  is  disturbed,  there 
is  a  tendency  to  diarrhoea;  the  facial  aspect  may  be  altered,  there 
are  blue  rings  round  the  eyes,  eruptions  on  the  skin,  tendency  to 
sweating,  palpitation  and  feeling  of  anxiety,  and  a  sensation  in  the 
extremities  as  if  they  had  been  beaten.  Local  symptoms  also  occur: 
disturbances  of  the  function  of  micturition,  swelling  of  the  breasts, 
pains  and  colics  in  the  renal  region,  feeling  of  warmth  in  the  genital 
organs,  pruritus  vulvse,  sensation  of  weight  in  the  uterus,  and  a 
strong  impulse  toward  coition.  The  secretions  may  be  pathological, 
sometimes  there  are  profuse  sweats,  sometimes  profuse  mucous  or 
bilious  diarrhoea,  whilst  the  urine  may  either  be  very  abundant, 
almost  colorless,  and  nearly  free  from  saline  matter,  or  thick  and 
overladen  with  phosphates  and  urates. 

Schauta  writes  regarding  the  complex  of  menstrual  phenomena 
which  occur  in  normal  menstruation :  "  In  the  process  of  men- 


THE  SEXUAL  EPOCH  OF  THE  MENARCHE.  145 

struation,  blood  and  sanguineous  mucus  find  their  way  through  a 
mucous  canal,  the  normal  calibre  of  which  is  merely  a  capillary 
fissure.  If  the  flow  is  slow,  without  the  formation  of  coagula,  and 
if  the  passage  through  the  cervix  is  free,  very  gentle  contractions 
of  the  uterine  muscle  suffice  on  the  whole,  as  the  blood  exudes  into 
the  cavity  of  the  uterus,  to  expel  it  into  the  vagina.  Without  such 
contractions,  menstruation  is  hardly  conceivable.  Physiologically, 
they  are  characterized  by  a  bearing-down  sensation,  passing  down 
toward  the  thighs,  and  by  pains  in  the  back.  It  is  rarely,  that  no 
pain  at  all  is  experienced ;  there  are  some  women,  however,  who 
affirm  that  in  their  case  menstruation  begins  quite  unexpectedly, 
and  without  the  slightest  warning;  but  it  does  not  follow  that  con- 
tractions of  the  uterus  do  not  occur  in  these  women  also  during 
menstruation.  *  *  *  The  local  disturbances  which  occur  as  an 
accompaniment  even  of  physiological  menstruation  are,  a  sensa- 
tion of  fulness  and  weight  in  the  pelvis,  and  pains  in  the  lower  part 
of  the  back,  and  these  probably  all  result  from  the  uterine  con- 
tractions. The  general  disturbances  of  a  reflex  nature  consist  of 
tenderness  on  pressure  in  the  epigastrium,  headaches,  general  sense 
of  languor,  irritability,  and  an  inclination  to  shed  tears.  Among 
changes  in  the  functions  of  remote  organs  may  be  mentioned,  swell- 
ing of  the  breasts,  of  the  vocal  cords,  and  of  the  thyroid  body,  in- 
creased respiratory  capacity  shortly  before  menstruation  followed 
by  rapid  decrease  during  the  flow,  tendency  to  diarrhoea,  nausea, 
vomiting,  flatulence,  salivation,  profuse  secretion  of  the  sebaceous 
glands  of  the  vulva,  increased  secretion  of  sweat,  tendency  to  the 
formation  of  acne  pustules.  The  mental  condition  also  exhibits 
as  a  rule  a  considerable  change  during  menstruation,  even  in  cases 
which  cannot  in  any  sense  be  regarded  as  pathological.  In  many 
instances,  an  apparently  normal  woman  may  during  menstruation 
exhibit  a  mental  state  so  abnormal  that  we  are  led  to  speak  of  it 
as  a  menstrual  psychosis.  Apart  from  this,  however,  it  appears  that 
during  menstruation  the  mental  life  of  woman  never  remains  en- 
tirely unaffected.  Finally,  we  must  mention  certain  changes  in  the 
sense-organs  which  not  infrequently  accompany  menstruation,  such 
as  herpes  conjunctivse,  exophthalmos,  limitation  of  the  visual  field, 
and  swelling  of  the  nasal  turuinate  bodies." 

In  the  digestive  organs,  during  the  menstrual  process,  changes  in 
the  secretions  of  the  glands,  nausea,  vomiting,  and  flatulence  are  not 
infrequently  observed.  In  one-half  of  the  women  concerning  whose 
state  during  menstruation  Krieger  made  inquiries,  he  found,  espe- 
cially just  before  and  during  the  discharge,  a  tendency  to  diarrhoea, 
or  at  least  to  more  copious  and  more  frequent  evacuations  of  the 
bowels  than  occurred  at  other  times.  On  the  surface  of  the  tongue, 

10 


146  THE  SEXUAL  LIFE  OF  WOMAN. 

at  the  premenstrual  epoch,  a  pronounced  exfoliation  of  the  epi- 
thelium may  occur,  so  that  in  some  instances  the  papillae  are  entirely 
exposed. 

Not  infrequently  hyperaemia  of  the  liver  appears  to  be  connected 
with  the  menstrual  process;  and  by  many  observers,  among  whom 
Senator  and  Fleischmann  may  be  mentioned,  jaundice,  slight  or  in- 
tense, has  been  seen  to  occur  during  menstruation.  In  a  case  of 
long-standing  amenorrhcea,  Duncan  noted  the  appearance  of  a 
transient  vicarious  jaundice,  apparently  reflex  in  its  origin.  In  some 
cases,  jaundice  precedes  menstruation,  and  disappears  as  the  flow 
becomes  established. 

In  the  respiratory  organs  also,  menstrual  changes  frequently  oc- 
cur. According  to  von  Ott,  respiratory  capacity  attains  a  maximum 
shortly  before  menstruation,  and  diminishes  rather  rapidly  during  the 
flow;  the  expiratory  power  is  similarly  affected.  In  the  larynx,  ac- 
cording to  Bottermund,  great  swelling  of  the  posterior  wall  occurs 
during  menstruation,  whereby  the  closure  of  the  glottis  is  hindered, 
and  a  rapid  onset  of  fatigue  ensues  in  the  muscles  that  perform  this 
action  when  the  woman  sings  or  speaks;  the  fulness  of  the  voice 
is  also  diminished.  More  or  less  extensive  swelling  of  the  thyroid 
body32  occurs  during  the  menstrual  period.  According  to  Fliess, 
in  most  women,  the  inferior,  sometimes  the  middle  and  the  inferior 
nasal  turbinate  bodies  are  greatly  swollen ;  sometimes  also  the  tuber- 
cula  septi  are  swollen.  It  is  said  that  the  right  half  of  the  nose  is 
more  frequently  and  more  intensely  swollen  than  the  left  half. 
Epistaxis  is  sometimes  observed  at  the  menstrual  periods. 

In  the  urinary  organs,  the  influence  of  the  menstrual  period  is 
manifested  by  a  change  in  the  urine.  According  to  Schroder,  the 
elimination  of  urea  is  diminished  shortly  before  menstruation;  ac- 
cording to  Laval,  the  elimination  of  uric  acid  undergoes  a  sudden 
diminution  on  the  second  day  of  the  flow,  followed  by  an  increase 
on  the  third  day,  subsequently  rising  above  the  normal  level.  This 
change  is  to  be  attributed,  not  to  any  excitation  of  the  genital 
organs,  but  to  the  loss  of  blood. 

Hebra  already  drew  attention  to  the  connection  between  diseases 
of  the  skin  and  the  physiological  and  pathological  processes  occur- 
ring in  the  female  genital  organs;  and  emphasized  the  fact  that  for 
the  cure  of  certain  eruptions,  local  treatment  of  the  disorder  of  the 
reproductive  organs  was  requisite.  He  gave  four  examples  of  such 
eruptions :  I,  an  acute  attack  of  eczema,  which  disappeared  only 
after  the  removal  of  a  badly  fitting  pessary;  2,  in  a  chlorotic  girl, 
two  large  red  spots  on  the  cheeks  disappeared  when  menstruation 
was  established;  3,  improvement  of  a  skin-affection  when  a  co- 

32  See  note  26  to  p.  107. 


THE  SEXUAL  EPOCH  OF  THE  MENARCHE.  147 

existing  disorder  of  the  genital  organs  received  appropriate  treat- 
ment, followed  by  recrudescence  of  the  skin  trouble  when  the  genital 
disorder  became  more  severe;  4,  a  case  of  obstinate  seborrhcea,  last- 
ing for  many  years,  which  disappeared  only  when  the  patient  became 
pregnant,  for  the  first  time,  seven  years  after  her  marriage. 

Similar  cases  have  been  recorded  by  subsequent  observers,  and 
numerous  monographs  have  been  published  on  menstrual  skin-erup- 
tions. Sfhramm,  for  instance,  reports  the  case  of  a  woman  in 
whom  at  each  menstrual  period  tubercles  and  papules  appeared  on 
the  backs  of  the  hands  and  on  the  neck ;  and  the  same  author  men- 
tions another  case  in  which  during  menstruation  red  papules  ar- 
ranged in  rows  appeared  on  the  back.  Wilhelm  observed  dark  blue 
.  macules,  the  size  of  hazelnuts,  which  appeared  on  the  thighs  shortly 
before  menstruation  and  disappeared  when  the  flow  was  over.  Of 
two  cases  of  menstrual  disorder  of  the  skin  reported  by  Stiller,  in 
one,  an  itching  eruption  appeared  on  the  upper  and  the  lower  ex- 
tremities ;  in  the  other,  small  red  papules  appeared  on  the  dorsum  of 
the  hands  and  feet.  Other  cases  of  menstruat  skin-eruptions  were 
published  by  Joseph,  Pauli,  Janovsky,  and  S  chiving.  Sometimes  at 
the  menstrual  periods  severe  pruritus  vulvre  occurs,  due,  no  doubt, 
to  the  temporary  increase  in  the  secretion  of  the  menstrual  passages, 
and  to  the  more  active  influence  exercised  by  this  secretion  on  the 
vulva. 

In  two  cases  in  which  the  menstrual  flow  was  in  abeyance,  Heitz- 
mann  observed  affections  of  the  skin.  In  one  of  these,  a  young 
woman  aged  twenty  who  had  not  yet  begun  to  menstruate,  there 
appeared  every  four  weeks  isolated  papules  surrounded  by  a  bright 
red  areola,  itching  so  violently  that  scratching  resulted.  In  the 
other,  macules  the  size  of  a  lentil,  of  a  light  red  or  dark  red  color, 
appeared,  and  lasted  two  or  three  days;  when  menstruation  became 
regular,  fresh  crops  no  longer  formed. 

Schauta,  in  a  case  of  chronic  oophoritis,  observed  the  regular  re- 
currence of  urticaria  at  each  successive  menstrual  period.  The 
suffering  being  very  great,  the  rest  at  night  being  greatly  disturbed 
during  the  periods  of  eruption,  and  the  patient's  general  health  de- 
clining more  and  more  in  consequence,  extirpation  of  the  ovaries 
was  undertaken,  and  the  operation  resulted  in  a  complete  cure. 
Schauta  further  observed  that  in  cases  of  obstinate  skin-affections 
of  unknown  causation  occurring  in  persons  of  the  female  sex,  some 
disorder  of  the  genital  organs  was  nearly  always  present;  more- 
over, in  many  of  these  cases,  as  soon  as  the  genital  disorder  was 
cured  by  appropriate  measures,  the  skin-affection  disappeared  spon- 
taneously and  without  any  further  treatment.  He  had  been  able  to 
collect  twenty-six  cases  of  this  nature,  in  which  an  indubitable 


148  THE  SEXUAL  LIFE  OF  WOMAN. 

connection  obtained  between  disease  of  the  skin  and  disease  of 
the  reproductive  system.  The  forms  of  affection  of  the  genital 
organs  chiefly  noticed  in  this  association  were,  retroflexion  and 
retroversion  of  the  uterus,  erosion  and  ectropium  or  eversion  of 
the  cervix  (chronic  cervical  catarrh),  chronic  endometritis, 
oophoritis,  and  salpingitis,  and  finally  with  especial  frequency 
uterine  myomata ;  the  skin-diseases  observed  were,  acne,  eczema, 
disorders  of  pigmentation,  psoriasis,  lichen,  and  urticaria. 

During  menstruation  we  observe  not  infrequently  a  number  of 
changes  in  the  skin,  such  as  hyperidrosis,  acne,  seborrhcea,  erythema, 
and  the  form  of  dermatitis  known  as  erysipelas  of  menstruation; 
sometimes  also  effusion  of  blood  into  the  skin  as  a  form  of  vicarious 
menstruation,  and  peculiar  forms  of  cutaneous  oedema.  In  many 
women  during  menstruation  the  secretion  of  sweat  is  markedly  in- 
creased every  month ;  in  exceptional  cases,  menstruation  is  vicari- 
ously replaced  by  profuse  sweating.  In  association  with  menstrua- 
tion we  frequently  observe  excessive  secretion  of  the  sebaceous 
glands,  especially  of  those  of  the  hairy  scalp.  Often  urticaria  mani- 
fests itself  as  a  recurrent  menstrual  eruption.  In  cases  of  scanty 
menstruation  and  of  amenorrhcea,  discoloration  and  excessive  pig- 
mentation of  the  skin  may  occur,  sometimes  taking  the  form  (as 
also  in  pregnancy)  of  chloasmia  uterinum.  Sometimes  also  in  these 
cases  the  formation  of  dark  rings  round  the  eyes,  already  seen  in 
slighter  degree  as  an  accompaniment  of  normal  menstruation,  is 
excessive. 

In  the  organ  of  vision,  changes  associated  with  menstruation  have 
been  recorded  by  various  observers,  tfordeolum  menstruale  (men- 
strual stye)  may  recur  month  after  month  at  the  menstrual  periods 
as  an  exacerbation  of  a  chronic  conjunctivitis.  .  Herpes  of  the  ocular 
or  palpebral  conjunctive  and  eczematous  affections  may  be  con- 
nected with  menstruation ;  also  exophthalmos  may  occur  during 
menstruation  in  association  with  swelling  of  the  thyroid  body  and 
palpitation  of  the  heart  (H.  Colin}  ;  again,  as  an  accompaniment  of 
normal  menstruation,  severe  papillitis  with  retinal  haemorrhages 
may  occur  (Heber).  According  to  the  investigations  of  Finkclstein, 
a  limitation  of  the  field  of  vision  may  be  noticed  during  menstrua- 
tion, beginning  on  the  first,  second,  or'  third  day  of  the  flow,  at- 
taining its  greatest  intensity  on  the  third  or  fourth  day  of  the  flow, 
and  gradually  disappearing  during  the  three  or  four  days  next 
ensuing. 

The  organ  of  hearing  is  stated  by  Hang  to  be  affected  during 
menstruation,  inasmuch  as  congestive  redness  and  swelling  of  the 
external  ear,  of  the  external  auditory  meatas,  and  of  the  skin  over  the 
mastoid  process,  sometimes  occurs ;  occasionally  also,  periodic  neu- 
ralgia manifests  itself  at  the  menstrual  periods. 


THE  SEXUAL  EPOCH  OF  THE  MENARCHE.  149 

In  the  circulatory  organs,  as  already  mentioned,  normal  menstrua- 
tion quite  frequently  manifests  its  influence  by  the  production  of 
disorders  of  greater  or  less  severity,  referable  to  the  stimulus  of 
ovulation.  In  8.5  per  cent,  of  the  women  of  whom  I  have  made 
inquiries  with  regard  to  -this  matter,  palpitation  of  the  heart  of 
variable  severity  occurred  during  menstruation,  and  was  most  fre- 
quent and  most  severe  on  the  first  and  second  days  of  the  flow. 
Associated  with  the  palpitation  in  some  cases  were,  vasomotor  dis- 
turbances, transient  feelings  of  heat,  a  sense  of  congestion  in  the 
head,  and  profuse  perspiration  without  apparent  cause.  The  day 
before  the  commencement  of  the  flow,  the  blood-pressure  rises  con- 
siderably, but  falls  rapidly  during  the  flow.  This  menstrual  rise 
in  blood-pressure  is  accompanied  by  a  rise  in  temperature  and  an 
increase  in  metabolic  activity.  The  influence  of  menstruation  on 
the  heart  is  m«st  powerfully  displayed  in  cases  in  which  for  some 
reason  a  disturbance  occurs  of  the  normal  appearance  or  normal 
course  of  menstruation. 

Disorders  of  menstruation  likely  to  give  rise  to  cardiac  disorders 
are,  amenorrhoea,  menorrhagia,  and  dysmenorrhoea. 

Amenorrhoea  is  especially  apt  to  induce  cardiac  disorder  in  cases 
in  which,  in  consequence  of  some  sudden  impression,  such  as  a 
fright  or  a  severe  chill,  menstruation,  which  began  at  puberty  in 
normal  fashion  and  subsequently  recurred  with  perfect  regularity, 
has  undergone  sudden  and  complete  suppression ;  also  in  cases  in 
which  severe  anaemia  or  obesity  has  rapidly  led  to  the  onset  of 
amenorrhoea.  In  such  cases,  attacks  of  tachycardia  sometimes  oc- 
cur, it  may  be  at  irregular  intervals,  or  it  may  be  exhibiting  a 
menstrual  rhythm,  the  cardiac  affection  manifesting  itself  always 
a  few  days  before  the  date  at  which  menstruation  ought  to  begin. 
In  these  cases,  also,  systolic  murmurs  are  not  infrequently  audible. 

In  cases  in  which  menstruation  is  very  painful,  the  dysmenorrhoea 
may  give  rise  to  attacks  of  colic  or  to  convulsive  seizures,  whether 
the  dysmenorrhoea  is  itself  due  to  inadequacy  or  to  complete  sup- 
pression of  the  flow,  to  metritis,  to  anteflexion,  to  new  growths  in 
the  uterus,  or,  finally,  to  diseases  of  the  ovaries  or  to  pathological 
disorders  of  ovulation.  Among  the  various  disorders  associated 
with  dysmenorrhcea,  heart  troubles  are  not  infrequent,  most  often 
taking  the  form  of  reflex  neuroses,  evoked  by  the  stimulus  of  the 
pain  in  the  genital  organs ;  but  it  has  also  been  asserted  that  an 
acute  dilatation  of  the  heart  occurs  in  these  attacks. 

Very  threatening  cardiac  symptoms  as  an  accompaniment  of 
severe  dysmenorrhoea  have  been  seen  by  me  especially  in  the  case 
of  two  women,  one  of  whom  was  in  the  thirties  and  the  other  in 
the  forties.  The  attacks  took  the  form  of  increased  frequency  of 


150  THE  SEXUAL  LIFE  OF  WOMAN. 

the  heart's  action,  with  severe  cardiac  dyspnoea  on  trifling  exertion, 
sense  of  suffocation,  and  intense  anxiety.  This  severe  cardiac  and 
respiratory  distress  was  a  sequel  to  the  appearance  of  severe  dys- 
menorrhcea,  and  was  relieved  as  soon  as  the  course  of  menstrua- 
tion became  regular  and  painless;  but  the  cardiac  trouble  recurred 
in  association  with  each  successive  attack  of  dysmenorrhcea.  In 
one  of  these  two  women,  the  dysmenorrhcea  was  the  result  of  ex- 
treme anteflexion  of  the  uterus;  in  the  other  woman,  the  cause  of 
the  dysmenorrhcea  was  not  apparent.  I  was  unable  to  decide  with 
certainty  whether  in  these  cases  an  acute  dilatation  of  the  heart 
occurred.  French  authorities,  who  describe  similar  cardiac  trouble 
resulting  from 'diseases  of  the  liver  and  the  stomach  by  the  name 
of  asystolie  gastrohcpatique  (Potairi),  give  the  following  explana- 
tion of  its  mode  of  occurrence.  The  infra-abdominal  plexus  of  the 
sympathetic  is  stimulated,  this  stimulus  is  reflected  to  the  lungs,  in 
which  organs  it  gives  rise  to  vaso-constriction,  resulting  in  increased 
tension  in  the  lesser  circulation ;  in  consequence  of  this  the  right 
heart  has  difficulty  in  emptying  itself,  when  weak  it  undergoes  dilata- 
tion, and  a  moderate  or  extreme  tricuspid  insufficiency  ensues.  \Ye 
have  to  do,  then,  in  these  cases,  with  reflex  symptoms,  with  a  reflex 
arc,  the  starting  point  of  which  is  the  sensory  nerve-terminals  in  the 
abdomen,  the  afferent  tract  of  which  is  formed  by  the  sympathetic 
and  pneumogastric  nerves,  and  the  efferent  tract  of  which  passes 
along  the  pulmonary  sympathetic  nerves. 

In  other  cases  of  dysmenorrhcea  we  observed  signs  of  cardiac 
weakness ;  the  pulse  was  small,  very  frequent,  and  barely  perceptible, 
the  face  became  suddenly  pale,  the  hands  and  feet  were  cold ;  com- 
plete syncope  sometimes  occurred. 

Menorrhagia  sometimes  leads  to  cardiac  symptoms,  owing  to  the 
severity  of  the  anaemia  which  follows  extensive  and  long-continued 
loss  of  blood ;  sometimes,  however,  the  heart  troubles  associated 
with  menorrhagia  are  reflex  manifestations,  dependent  on  the  dis- 
ease which  has  also  caused  the  menorrhagia,  endometritis,  it  may 
be,  new  growths,  lukaemia,  or  scurvy.  Sometimes  here  also  we 
observe  transient  attacks  of  acute  dilatation  of  the  heart. 

Nervous  disturbances  during  menstruation,  which  are  so  fre- 
quent that  Emmet  regards  it  as  abnormal  for  a  menstruating 
woman  to  be  entirely  free  from  pain  and  from  uneasy  sensations, 
are  divided  by  Witidscheid  into  two  classes,  general  nervous  dis- 
orders, and  local  nervous  manifestations.  Among  general  disorders, 
the  commonest  is  a  general  bodily  incapacity;  in  women,  who  in 
other  respects  are  quite  healthy,  during  menstruation  everything 
will  be  too"  great  an  exertion,  and  fatigue  speedily  ensues  on 
the  performance  of  occupations  which  at  other  times  are  under- 


THE  SEXUAL  EPOCH  OF  THE  MENARCHE.  151 

taken  without  the  slightest  difficulty.  Another  common  nervous 
disorder  is  an  uneasy  sensation  in  the  head,  it  may  be  a  feeling  of 
weight  or  pressure,  sometimes  described  as  a  feeling  as  if  an  iron 
band  were  compressing  the  forehead.  Slight  mental  irritation  is 
commonly  present  also,  the  woman  is  capricious,  her  mental  equilib- 
rium is  disturbed.  Very  common  also  are  vasomotor  disturbances, 
transient  feelings  of  heat,  a  sense  of  congestion  in  the  head,  or  an 
outbreak  of  perspiration.  Among  local  nervous  disturbances,  Wind- 
schcid  enumerates,  pains  in  the  back  (occasionally  and  erroneously 
described  as  spinal  irritation),  sacrache,  pains  in  the  lower  extremi- 
ties, which  by  preference  generally  take  the  course  of  the  great 
sciatic  nerves.  Pains  in  the  abdomen  also  frequently  accompany 
menstruation ;  these  may  be  diffused  over  the  whole  abdomen,  or 
may  predominate  in  the  two  hypochondriac  regions.  Disorders  of 
the  sense-organs  sometimes  occurring  during  menstruation  are,  the 
flickering  of  objects  before  the  eyes,  photophobia,  and  tinnitus 
aurium.  The  heart  may  also  be  affected  with  palpitation  in  as- 
sociation with  these  nervous  disturbances;  the  stomach  may  exhibit 
associated  disorder  in  the  form  of  cardialgia,  or  more  frequently  in 
the  form  of  vomiting,  this  latter  being  very  frequent  at  the  outset  of 
the  flow.  Less  common  is  profuse  diarrhoea,  pain  in  the  anus,  or 
spasm  of  the  sphincter  ani. 

The  intensity  of  such  nervous  manifestations  during  menstrua- 
tion is  dependent  upon  the  woman's  general  state  of  nutrition,  upon 
the  degree  of  instability  of  her  nervous  system,  and  upon  her  occu- 
pation. Robust  and  powerful  women,  regularly  employed  in  the 
open  air,  such  as  the  wives  and  daughters  of  farmers  and  agricul- 
tural laborers,  are  much  less  affected  by  the  nerve-weakening  in- 
fluences of  menstruation  than  the  sedentary  and  anaemic  town-dwell- 
ing women,  whether  these  latter  belong  to  the  higher  classes  of 
society  and  are  addicted  to  nerve-straining  enjoyments,  or  to  the 
class  of  shop-girls,  seamstresses,  and  factory-women,  whose  employ- 
ment is  apt  to  lead  to  nervous  exhaustion. 

As  regards  the  forms  of  neuralgia  most  apt  to  accompany  men- 
struation, Windscheid  mentions  trigeminal  neuralgia  as  the  com- 
monest, especially  affecting  the  first  division  of  the  nerve,  and  pro- 
ducing localized  pains  which  are  to  be  distinguished  from  the  head- 
aches already  mentioned.  They  are  characterized  by  their  intensity 
and  their  persistence  in  spite  of  anti-neuralgic  treatment,  and  by  their 
spontaneous  disappearance  as  soon  as  menstruation  is  over.  Ac- 
cording to  the  same  author,  the  relations  between  hemicrania  and 
the  process  of  menstruation  are  indisputable ;  at  the  very  least  it 
must  be  admitted  that  menstruation  predisposes  to  an  attack  of 
hemicrania. 


1-- 


152  THE  SEXUAL  LIFE  OF  WOMAN. 

Cases  also  occur  in  which  convulsions  almost  invariably  accom- 
pany menstruation,  convulsions  which  are  to  be  regarded  as  symp- 
toms of  hysteria. 

The  extraordinarily  powerful  influence  which  the  menstrual 
stimulus  exercises  on  the  mind  is  shown  by  the  frequency  with 
which  the  slighter  psychopathic  states  occur  as  an  accompaniment 
even  of  normal  menstruation,  these  manifestations  being  sometimes 
melancholic  in  type,  sometimes  maniacal  or  erotic,  and,  when  of 
long  duration,  leading  ultimately  to  pronounced  mental  disorder. 
This  influence  of  the  menstrual  stimulus  is  yet  more  potent  in  cases 
in  which  important  changes  in  the  course  of  menstruation  have 
occurred,  in  cases,  for  instance,  of  suppressed,  painful,  or  irregular 
menstruation.  In  this  connection,  however,  in  order  to  avoid  a 
confusion  of  cause  and  effect,  we  must  carefully  bear  in  mind,  that 
it  is  a  much  commoner  causal  sequence  for  psychical  disorders  to 
disturb  the  normal  course  of  menstruation,  than  for  disorders  of 
menstruation  to  evoke  psychical  disorders.  This  view  has  only  quite 
recently  become  established,  and  for  this  reason  it  is  necessary  to 
regard  such  data  when  obtained  from  the  writings  of  the  older 
gynecologists  in  a  somewhat  critical  spirit. 

By  the  modern  alienist,  the  influence  of  the  menstrual  reflex  on 
mental  affections  is  recognized  only  in  cases  in  which  a  proper  valua- 
tion of  the  predisposing  causes  has  been  made,  in  such  cases  as  the 
following:  First,  we  have  to  recognize  the  modifying  influence 
exercised  by  the  menstrual  stimulus  on  established  psychoses,  inas- 
much as  these  latter  not  un frequently  undergo  cure  when  previously 
irregular  menstruation  has  become  regular,  and,  moreover,  the  re- 
currence or  the  first  appearance  of  menstruation  has  often  a  power- 
ful influence  on  the  course  of  some  established  mental  disorder. 
In  some  cases  this  influence  is  a  strikingly  favorable  one  on  psy- 
choses that  have  developed  before  the  commencement  of  menstrua- 
tion, or  during  the  suppression  of  that  function  ;  it  may  be,  however, 
and,  indeed,  more  frequently  is,  an  unfavorable  influence,  inasmuch 
as  such  a  psychosis,  on  the  first  appearance  or  on  the  reappearance  of 
menstruation,  may  assume  a  menstrual  type,  the  attacks  becoming 
more  frequent  or  more  violent  with  the  successive  recurrence  of 
each  menstrual  or  premenstrual  period.  This  is  the  history  of  the 
typical  menstrual  psychosis. 

Again,  certain  processes  of  the  sexual  life,  disorders  of  menstrua- 
tion, diseases  of  the  genital  organs,  operations  on  these  organs,  and 
the  processes  of  the  climacteric,  influence  the  origin  and  the  character 
of  mental  disorder,  generally  giving  rise  to  chronic  affective  in- 
sanity (insanity  of  the  emotions  and  feelings)  or  to  paranoia 
(chronic  delusional  insanity,  insanity  of  the  intellect).  The  men- 


j  FJ  2  J  J  C  ^j 


THE  SEXUAL  EPOCH  OF  THE  MENARCHE.  153 

strual  stimulus  must  in  these  cases  be  regarded  as  a  psychopathically 
exciting  physical  cause. 

Further,  physical  disturbances  may  equally  affect  the  menstrual 
function  and  the  functions  of  the  mind,  rendering  the  exact  causal 
sequence  in  such  cases  a  difficult  one  to  determine ;  and,  conversely, 
the  circumstances  that  restore  the  normal  working  of  the  mind  may 
also  regulate  the  menstrual  function. 

Finally,  we  may  have  to  do  with  isolated  sporadic  occurrences  in 
which  the  exciting  influence  of  menstrual  processes  may  be  traced. 
Thus,  for  the  outbreak  of  a  periodical  menstrual  psychosis,  an  espe- 
cial temporal  predisposition  must  exist,  connected  with  the  great 
developmental  epoch  of  the  sexual  life. 

There  is,  for  instance,  a  group  of  transitory  states  occurring  dur- 
ing menstruation,  and  taking  the  form  of  disorders  of  the  intelli- 
gence or  of  explosive  emotional  states ;  such  may  be  witnessed,  not 
in  those  suffering  from  psychopathic  predisposition,  but  in  quite 
healthy  individuals. 

The  successive  menstruations  as  they  recur  regularly  throughout 
the  course  of  the  sexual  life  may,  just  like  the  first  menstruation, 
though  with  diminished  intensity,  give  rise  to  manifestations  of 
nervous  and  mental  disorders.  In  many  women  who  are  in  other 
respects  healthy,  we  see  during  menstruation,  hemicrania,  nervous 
irritability,  ill-temper,  low-spiritedness,  and  even  hysterical  and 
epileptic  attacks ;  these  occur  chiefly  on  the  first  and  second  days  of 
the  flow,  and  disappear  altogether  toward  the  end  of  the  period. 
These  manifestations  are  more  severe  in  individuals  weakened  by 
profuse  losses  of  blood  or  by  chronic  disorder  in  various  organs, 
more  severe  also  in  those  predisposed  to  such  disturbances  in  con- 
sequence of  neuropathic  inheritance,  more  severe  in  women  suffer- 
ing from  menorrhagia  and  dysmenorrhoea,  and  from  any  kind  of 
mental  stress. 

In  his  work  on  the  influence  of  the  so-called  menstrual  wave  on 
the  course  of  mental  disorders,  Schiile  remarks  that  the  mental 
equilibrium  even  of  a  perfectly  healthy  woman  is  not  a  stable  one, 
but  is  subject  to  a  series  of  oscillations.  '  The  menstrual  period,'* 
he  continues,  "  has  a  distinct  influence  on  woman's  mental  equilib- 
rium. Even  in  those  whose  nervous  system  is  a  healthy  one,  men- 
struation evokes  a  state,  now  of  depression,  now  of  excitement;  in 
neurotic  women,  on  the  other  hand,  menstruation  may  give  rise  to 
nervous  diseases  which  may  equally  exhibit  the  characteristics  of 
depression  or  the  characteristics  of  excitement.  In  nervously  pre- 
disposed women,  the  influence  of  regularly  established  menstrua- 
tion, even  when  the  circumstances  are  favorable,  is  pretty  much  the 
same  as  the  influence  of  menstruation  when  it  first  makes  its  ap- 


154  THE  SEXUAL  LIFE  OF  WOMAN. 

pearance ;  the  influence  is  merely  somewhat  weaker  in  so  far  as  the 
woman  has  learned  to  endure  and  to  be  patient.  The  menstrual 
state,  in  nervously  predisposed  women,  evokes  the  particular  neurosis 
to  which  the  individual  happens  to  be  liable.  The  disorders  most 
commonly  met  with  in  this  association  are,  hysteria,  hemicrania, 
swimming  in  the  head,  epileptic  paroxysms,  toothache,  and  neu- 
rasthenia." 

Especially  frequent  during  menstruation  is  hemicrania.  Some- 
times hemicrania  may  begin  a  day  or  two  before  menstruation,  as  a 
prodromal  sign,  and  may  accompany  its  whole  course,  becoming, 
however,  less  s-evere  toward  the  end  of  the  flow.  Hysteria  most 
commonly  manifests  itself  in  association  with  menstruation  by  a 
depressed  emotional  state,  by  tearfulness,  by  complaints  made  with- 
out sufficient  grounds,  by  globus  hystericus  or  clavus  hystericus; 
sometimes  also  by  paroxysms  of  muscular  spasm ;  very  rarely  by 
hystero-epileptic  seizures.  Epilepsy  may  occur  either  by  day  or  by 
night.  Nocturnal  seizures  usually  occur  without  any  apparent  ex- 
ternal cause,  as  a  result  of  the  central  stimulus;  diurnal  attacks, 
on  the  other  hand,  have  usually  some  external  exciting  cause. 
Often,  however,  years  may  elapse  without  any  attack  of  major 
epilepsy  occurring,  the  disease  manifesting  itself  in  one  or  more  of 
the  many  varieties  of  the  minor  form  (petit  mal),  as  transient 
absences  of  mind,  attacks  of  vertigo,  etc. 

The  nervous  disturbance  in  a  menstruating  woman  may  be  so 
great  as  to  lead  to  the  production  of  psychoses.  The  question  of 
the  existence  of  a  menstrual  insanity  sui  generis  has  been  answered 
by  many  alienists  in  the  affirmative ;  by  others,  however,  who  see 
in  the  alleged  cases  nothing  specific,  it  has  been  answered  in  the 
negative.  The  relation  of  menstruation  to  the  mental  disorder  may 
be  a  double  one:  I,  menstruation  may  occur  repeatedly  in  the 
course  of  an  already  established  mental  disorder;  2,  menstruation 
and  its  morbid  variations  may  favor  the  occurrence  of  psychoses 
that  exist  already  in  a  latent  form,  and  may  lead  to  the  origination 
of  psychoses  to  which  the  organism  in  predisposed. 

In  the  former  connection,  Brierre  de  Boismont  undertook  an  in- 
vestigation which  showed  that  in  women  suffering  from  mental 
disorder,  an  exacerbation  of  that  disorder  was  to  be  observed  dur- 
ing menstruation.  Schlagcr,  who  regards  the  menstrual  process  as 
possessing  when  anomalous  a  high  significance  for  the  develop- 
ment and  course  of  mental  disturbances,  observed  that  in  33  per 
cent,  of  women  suffering  from  mental  disorder,  the  menstrual  state 
had  an  unfavorable  influence  upon  the  course  of  that  disorder,  in- 
asmuch as  it  led  to  an  increased  irritability;  in  the  rest  of  the 
cases,  however,  menstruation  was  without  influence  upon  the  course 


THE  SEXUAL  EPOCH  OF  THE  MENARCHE.  155 

of  the  ordinary  chronic  psychoses.  In  the  cases  that  were  unfavor- 
ably influenced,  epileptic  attacks  usually  became  more  frequent, 
and  chronic  melancholia  became  much  more  profound.  Schroder 
observed  in  chronic  forms  of  melancholia  that  during  menstrua- 
tion the  sadness  became  intolerable  and  was  associated  with  a 
suicidal  tendency;  in  chronic  maniacal  forms  of  mental  disorder, 
the  excitement  underwent  an  increase  during  menstruation.  Von 
Krafft-Ebing,  as  a  result  of  his  investigations  into  insanity  during 
menstruation,  came  to  similar  conclusions  with  regard  to  the  un- 
favorable influence  of  the  menstrual  process.  Algeri  likewise  states 
that  menstruation  notably  aggravates  the  cerebral  symptoms  in  the 
course  of  mental  disorders. 

Other  authors,  Marce  and  Kowalewski  for  instance,  whilst  em- 
phasizing the  powerful  influence  exerted  by  menstruation  on  any 
existing  psychosis,  point  out  that  in  some  instances,  as  in  states  of 
mental  and  physical  depression,  this  influence  is  for  the  worse ;  but 
in  other  instances,  especially  in  states  of  maniacal  excitement,  the 
condition  of  the  patient  undergoes  notable  amelioration  during  men- 
struation. Schafcr  also,  in  his  researches  into  the  relations  between 
the  processes  of  menstruation  and  psychoses,  discovered  that 
anomalies  in  the  course  of  menstruation  ran  almost  parallel  with 
anomalies  in  the  course  of  mental  activity. 

In  psychopathically  predisposed  women,  disorders  of  menstrua- 
tion, such  as  amenorrhoea,  delayed  menstruation,  and  dysmenorrhoea, 
are  more  effective  than  the  normal  process  of  menstruation  in  evok- 
ing manifestations  of  psychical  abnormalities  previously  latent,  and 
in  leading  to  attacks  of  precordial  anxiety,  pathological  emotional 
states,  melancholic  seizures,  epilepsy  in  all  its  varieties,  and  impul- 
sive manifestations,  such  as  pyromania,  kleptomania,  infanticide, 
homicide,  etc.  As  results  of  a  special  predisposition  may  appear 
in  this  connection,  congenital  imbecility,  idiocy,  melancholia,  and 
chronic  weak-mindedness. 

A  rich  literature  exists  of  cases  in  which  mental  abnormalities 
occurred  in  psychopathically  predisposed  individuals  as  a  result  of 
menstruation.  Thus,  von  Krafft-Ebing  reports  a  case  in  which, 
during  menstruation,  a  mentally  undeveloped  woman  murdered  her 
husband ;  and  another  case  in  which  to  chronic  weak-mindedness 
and  chronic  delusional  insanity  were  superadded  during  menstrua- 
tion peculiar  attacks  having  the  character  of  psychical  storms.  Tuke 
reports  a  case  in  which  a  mother,  in  a  state  of  alcoholic  excess  dur- 
ing menstruation,  murdered  her  daughter.  Pclmann  records  acts 
of  pyromania  committed  during  menstruation  by  a  girl  seventeen 
years  of  age.  Mabillc  records  a  case  in  which  a  woman  suffering 
from  severe  mental  disorder  was  affected  during  menstruation  by 


156  THE  SEXUAL  LIFE  OF  WOMAN. 

impulsive  kleptomania,  whilst  after  the  periods  the  memory  of  what 
had  happened  passed  away.  Philo-lndicus  records  the  case  of  a 
woman  suffering  from  severe  neuropathy  who  at  the  menstrual 
periods  exhibited  great  irritability,  experienced  marked  sexual  ex- 
citement, and  had  suicidal  impulses,  and  who  on  one  occasion  at- 
tempted to  murder  a  female  friend  who  had  refused  to  assist  her 
in  the  practice  of  sexual  aberrations.  Giraud  describes  a  woman 
suffering  from  passive  melancholia,  in  whom  during  menstruation 
horrible  fantastic  ideas  occurred.  Ball  records  the  case  of  a  woman 
who  suffered  always  from  acute  mental  disorder  during  menstrua- 
tion, and  who,  in  one  of  these  attacks,  murdered  her  son.  Kowalew- 
ski  reports  a  case  of  chronic  imbecility,  in  which  during  menstrua- 
tion attacks  of  precordial  anxiety  developed,  and  in  the  course  of 
one  of  these  attacks  the  patient  set  fire  to  her  own  house.  "  In 
such  cases,"  remarks  Kowalewski,  "  menstruation  represents  the 
last  drop  that  makes  the  full  goblet  overflow." 

In  addition,  we  meet  with  cases  in  which  the  influence  of  men- 
struation is  so  powerful  that  it  must  be  regarded  as  the  principal 
cause  of  the  psychosis.  We  must  then  speak  of  a  true  menstrual 
psychosis,  the  impulse  to  which  is  supplied  by  the  normal  or  ab- 
normal changes  occurring  in  the  process  of  menstruation,  and 
characterized  by  the  menstrual  periodicity  and  the  brief  duration 
of  the  attacks.  These  are  the  characteristics  of  the  menstrual  psy- 
choses of  the  menarche  and  of  the  climacteric  period ;  and  such 
cases  occur  also  during  the  period  of  full  menstrual  activity. 

The  menstrual  psychosis  most  commonly  makes  its  appearance 
shortly  before  the  flow,  becomes  less  severe  with  the  establishment 
of  the  flow,  and  disappears  when  the  flow  ceases ;  in  other  cases, 
the  psychosis  appears  toward  the  end  of  menstruation,  and  speedily 
passes  away ;  or,  again,  in  amenorrhoeic  cases,  the  attacks  of  mental 
disorder  replace  the  proper  menstrual  flow,  and  become  less  severe 
or  disappear  entirely  as  soon  as  the  flow  is  regularly  re-established. 
The  commonest  forms  of  these  menstrual  psychoses  are,  melancholia, 
mania,  irresistible  impulses,  acute  amentia,  in  rare  cases  alternating 
insanity  (folie  circulaire}  in  which  the  periods  of  alternation  as- 
sume the  menstrual  rhythm.  The  duration  of  these  psychoses  is 
usually  short,  from  a  few  days  up  to  a  fortnight ;  there  may  be  only 
a  single  attack,  or  there  may  be  a  number  of  attacks  presenting 
precisely  similar  characters. 

The  consciousness  may  be  more  or  less  disturbed.  Von  Krafft- 
Ebing  points  out,  as  a  very  dangerous  peculiarity  of  the  menstrual 
psychoses,  that  the  fact  that  the  morbid  process  has  once  occurred 
in  connection  with  menstruation  furnishes  in  itself  a  sufficient  rea- 
son for  the  recurrence  of  such  attacks,  which  are  dependent  on 


THE  SEXUAL  EPOCH  OF  THE  MENARCHE.  157 

constantly  repeated  functional  changes  in  the  brain  closely 
analogous  to  those  that  occur  in  epilepsy.  When  the  menstrual 
insanity  recurs  frequently,  it  gradually  becomes  less  acute  in  its 
characters  and  more  protracted  in  its  course ;  the  lucid  intervals  are 
less  clearly  indicated  and  shorter  in  duration ;  and  thus  in  course  of 
time  the  mental  disorder  may  be  transformed  into  chronic  imbecility 
—  a  transformation  liable  to  occur  in  all  forms  of  periodic  psychosis. 
In  such  cases  we  must  always  assume  the  existence  of  a  certain  lack 
of  resisting  power  on  the  part  of  the  organism,  especially  of  the 
nervous  system,  which  amounts  to  a  congenital  predisposition.  Dur- 
ing the  period  of  full  menstrual  activity,  the  favorable  soil  for  the 
cultivation  of  such  disorders  is  usually  furnished  by  anomalies  of 
menstruation,  by  difficult  labor  and  its  consequences,  severe  losses 
of  blood,  prolonged  lactation,  physical  overexertion,  and  mental 
shock  and  stress. 

In  the  development  under  the  influence  of  menstruation  of  such 
periodic  acute  mental  disorders,  we  may  observe  various  gradations, 
as  for  instance  short,  syncope-like  cataleptic  seizures,  states  of 
hallucinatory  confusion  lasting  several  hours  or  several  days,  dis- 
ordered consciousness,  and  even  severe  mania. 

Such  a  case  was  observed  by  Wille.  Under  the  influence  of  men- 
struation and  of  a  trifling  source  of  mental  disturbance  (having 
soldiers  billeted  on  them  in  a  quiet  country  village),  a  young  woman 
aged  twenty-one,  whose  mental  health  had  previously  been  good, 
had  a  sudden  attack  of  anxiety,  succeeded  by  a  violent  but  transitory 
mania,  lasting  five  or  six  hours ;  after  a  short  free  interval  came 
another  attack,  this  time  lasting  several  days.  Similar  cases  were 
recorded  by  Friedmann.  A  blooming  and  healthy  maid-servant 
eighteen  years  of  age  (some  mental  unsoundness  was  recorded  in 
both  grandfather  and  aunt  on  the  maternal  side)  fell  asleep  in  a 
chair  a  few  days  before  menstruation,  awakened  with  a  start,  was 
srbsequently  disordered  in  mind,  though  tranquil,  with  many 
hallucinations,  listening  to  voices  which  repeated  monotonously 
"  they  come,"  was  drowsy,  and  slow  to  answer  when  spoken  to.  On 
the  third  day  she  was  recovered,  her  mind  being  clear  and  normal ; 
she  was  not  fully  aware  of  what  had  happened.  Since  this  attack, 
her  mind  has  been  free  from  disorder,  during  menstruation  as  well 
as  at  other  times.  She  is  said  to  have  had  a  similar  attack  about 
four  years  ago,  that  is,  at  the  commencement  of  puberty. —  A  girl 
aged  thirteen,  quite  healthy,  not  nervous,  physically  rather  power- 
ful, with  quite  healthy  family  history.  Complaints  of  having 
suffered  for  two  clays  from  general  sense  of  depression  with  pains 
in  the  abdomen ;  during  the  afternoon  was  lying  on  a  sofa,  but 
suddenly  sprang  up,  looked  extremely  anxious  and  confused,  ran 


158  THE  SEXUAL  LIFE  OF  WOMAN. 

about  the  room,  begged  to  be  protected  from  the  black  man,  etc., 
her  speech  was  disconnected,  gabbling,  and  difficult  to  understand. 
After  two  hours  she  became  quiet,  and  fell  into  a  sound  sleep,  from 
which  she  awoke  calm  and  quite  forgetful  of  what  had  passed.  ( )n 
the  following  day  menstruation  appeared  for  the  first  time,  with 
abdominal  pains,  but  without  any  mental  abnormality.  During  the 
subsequent  six  years  she  has  remained  quite  well. 

Since  the  days  of  antiquity  an  extremely  important  part  has  been 
assigned  to  suppression  of  the  menses  in  the  production  of  mental 
disorders ;  but  in  the  opinion  of  modern  alienists,  who  are  opposed 
to  the  old  humoral  pathology,  no  more  is  to  be  recognized  in  this 
connection  than  the  ordinary  menstrual  stimulus,  which,  indeed, 
when  the  soil  is  already  prepared,  may  furnish  a  causal  determinant 
for  an  increase  in  the  intensity  of  an  already  existing  anomalous 
mental  condition.  Quite  recently  numerous  cases  have  been  pub- 
lished in  which  such  an  influence  has  been  recognized  as  powerful. 
yon  Krafft-Ebing  writes :  "  In  isolated  cases,  as  a  sequel  of  sudden 
cessation  of  the  menstrual  flow,  generally,  due  to  a  fright  or  to  a 
chill,  the  development  of  insanity  (usually  acute  mania)  has  been 
observed,  and  the  suppression  of  menstruation  has  been  regarded  as 
the  causal  determinant.  It  is  indeed  conceivable  that  the  connection 
between  the  two  events  is  supplied  by  a  collateral  vicarious  conges- 
tion of  the  brain.  As  a  rule,  however,  the  psychosis  and  the  sup- 
pression of  menstruation  are  the  coeffects  of  the  same  cause,  and 
are  both  of  vasomotor  origin." 

Mairet  reports  a  case  of  violent  mental  disorder  of  a  maniacal 
type,  associated  with  chorea,  occurring  at  puberty,  the  exciting  cause 
of  which,  in  a  constitution  hereditarily  predisposed  to  insanity,  he 
believed  to  be  suppression  of  the  menses.  Diamant  had  under  obser- 
vation a  girl  in  whom,  at  the  age  of  six  years,  menstruation  ceased, 
having  previously  been  regular  since  the  age  of  two  years;  after  the 
suppression  of  menstruation,  violent  epileptiform  seizures  set  in, 
occurring  at  what  should  have  been  the  menstrual  periods.  \Vest- 
phal  described  a  case  of  infanticide  committed  in  a  state  of  melan- 
cholia at  the  proper  menstrual  period,  the  menses  being  suppressed. 

Menstrual  psychoses  are  observed  for  the  most  part  in  compara- 
tively young  women  ;  after  the  age  of  thirty-five  they  are  uncommon. 
Among  von  Krafft-Ebing  s  cases  there  were : 

4  patients  between  the  ages  of 15  and  20  years. 

6  patients  between  the  ages  of 20  and  25  years. 

2  patients  between  the  ages  of 25  and  30  years. 

6  patients  between  the  ages  of 30  and  35  years 

2  patients  above  the  age  of 35  years. 

The  same  author  insists  that  for  the  development  of  a  menstrual 
psychosis  a  predisposition  on  the  part  of  the  brain  must  exist,  either 


THE  SEXUAL  EPOCH  OF  THE  MENARCHE.  159 

in  the  form  of  an  inherited  predisposition,  or  in  the  form  of  a  primary 
mental  disorder,  or,  finally,  as  the  result  of  some  special  exciting 
cause,  such  as  emotional  disturbance,  the  abuse  of  alcohol,  or  bodily 
illness.  Among-  19  cases  observed  by  von  Krafft-Ebing 

12  were  hereditarily  predisposed. 

4  had  previously  exhibited  great  nervousness  during  menstruation. 
7  suffered  from  primary  mental  weakness. 

Very  remarkable  is  the  influence,  demonstrated  especially  by 
Lombroso,  exercised  by  menstruation  on  the  commission  of  certain 
crimes.  Of  eighty  women  taken  into  custody  for  resisting  the  police, 
there  were  nine  only  who  were  not  menstruating  at  the  time.  Four 
notorious  murderesses  and  one  woman  convicted  of  arson  were  all 
menstruating  at  the  times  when  their  crimes  were  committed. 
Krngenstcin  found  evidence  of  menstruation  in  the  bodies  of  107 
women  who  committed  suicide.  Thefts  committed  by  ladies  in  the 
great  shops  of  Paris  are  most  commonly  effected  during  menstru- 
ation, as  was  found  by  Legrand  du  Saulle  to  be  the  case  in  thirty 
five  instances  out  of  fifty-six  investigated  by  him  in  respect  to  this 
matter.  According  to  the  same  author,  hysterical  girls  who  steal 
articles  of  clothing,  bottles  of  scent,  and  the  like,  from  the  counters 
of  shops,  are  almost  always  menstruating  at  the  time. 

Von  Krafft-Ebing  puts  forward  the  following  propositions  with 
regard  to  the  forensic  significance  of  offences  committed  by  women 
during  menstruation:  I.  The  mental  integrity  of  a  menstruating 
woman  is  questionable  from  the  forensic  standpoint.  2.  In  the  case 
of  women  on  trial  for  any  offence,  the  point  should  be  determined 
whether  that  offence  was  committed  at  a  menstrual  period.  3.  An 
inquiry  into  the  mental  condition  is  expedient  in  cases  in  which 
such  a  coincidence  is  established ;  light  is  thrown  on  the  matter  when 
investigation  shows  the  existence  of  hereditary  predisposition,  when 
we  learn  that  psychopathic  manifestations  have  occurred  at  previous 
menstrual  periods,  or  when  the  very  nature  of  the  offence  is  one 
suggesting  the  presence  of  mental  disorder.  4.  A  recognition  of 
the  powerful  influence  which  the  menstrual  process  exercises  upon 
the  mental  life  should  lead,  even  in  cases  in  which  no  menstrual 
psychosis  has1  been  proved  to  exist,  to  the  admission  of  extenuating 
circumstances  in  apportioning  the  punishment  for  the  offence.  5.  In 
the  case  of  the  commission  of  a  punishable  act  during  menstruation 
by  a  weak-minded  individual,  we  must  as  a  rule  admit  the  plea  of 
irresponsibility  —  at  any  rate  in  the  case  of  an  offence  committed  un- 
der the  influence  of  strong  emotion.  6.  Persons  who  have  been  dis- 
charged without  punishment  on  the  plea  of  mental  disorder  accom- 
panying menstruation  must  be  regarded  as  dangerous  to  the  com- 
munity, and  should  always  be  under  careful  supervision  during  the 
menstrual  periods. 


160  THE  SEXUAL  LIFE  OF  WOMAN. 

Amenorrhcca,  Menorrhagia,  and  Dysmcnorrhcca. 

Amenorrhoea,  permanent  or  transient  abnormal  lack  of  the  men- 
strual flow,  may  depend  upon  anatomical  changes  in  the  genital 
organs,  upon  incomplete  development  or  absence  of  the  uterus  and 
the  ovaries,  upon  enduring  or  transient  defective  nutrition  or 
upon  atrophy  of  these  organs,  or  upon  parenchymatous  disease 
of  the  ovaries ;  or  it  may  be  due  to  functional  disturbances  of  ovarian 
activity,  itself  dependent  upon  changes  in  the  nervous  system,  upon 
constitutional  diseases,  or  upon  general  nutritive  disturbances  in 
the  body.  Among  the  latter  conditions  must  be  especially  mentioned 
chlorosis,  obesity,  diabetes,  chronic  alcoholism,  and  morphinism, 
myxoedema,  exophthalmic  goitre,  etc. 

The  amenorrhoea  that  occurs  at  the  time  of  the  menarche  has 
already  been  described  in  connection  with  the  symptomatology  of 
that  period. 

If  in  cases  of  amenorrhoea  the  ovaries  continue  to  perform  their 
functions,  we  frequently  witness  severe  and  painful  menstrual 
molimina,  occurring  periodically  at  the  times  when  the  flow  might 
be  expected,  but  fails  to  appear.  In  cases  of  atrophy  of  the  uterus 
and  the  ovaries,  we  see  complete  and  permanent  amenorrhoea  with- 
out any  discomfort.  As  a  kind  of  vicarious  menstruation,  in  certain 
cases  of  amenorrhoea,  we  see  haemorrhages  into  the  vitreous  body 
or  conjunctival  haemorrhages ;  also,  as  more  extensive  disturbances 
of  the  visual  organs,  interstitial  keratitis,  disseminated  choroiditis, 
intermittent  amaurosis,  acute  retrobulbar  neuritis,  amblyopia,  and 
limitation  of  the  field  of  vision. 

Mooren  publishes  the  following  cases,  showing  the  influence  of 
amaurosis  on  the  eye.  A  girl  aged  fourteen,  with  severe  bilateral 
pannous  keratitis,  was  amenorrhoeic  notwithstanding  the  existence 
of  well-marked  menstrual  molimina.  Every  four  weeks,  at  the  times 
when  the  menstrual  flow  should  have  appeared,  the  corneal  inflam- 
mation became  more  severe;  it  became  amenable  to  treatment  for 
the  first  time  a  year  later,  when  the  menstrual  flow  had  become 
established.  A  peasant  woman,  twenty-eight  years  of  age,  had  never 
menstruated ;  the  uterus  was  badly  developed ;  every  month  an  in- 
tolerable heat  and  swelling  of  the  face  recurred.  Since  the  age  of 
fifteen  she  had  suffered  from  bilateral  interstitial  keratitis,  which 
had  resisted  all  treatment,  and  had  been  subject  every  four  weeks 
to  a  recurrent  exacerbation  of  this  trouble,  lasting  several  days.  The 
exhibition  of  powerful  emmenagogues  and  the  use.  of  Friedrichshall 
water  brought  about  on  a  few  occasions  a  scanty  discharge  of  blood. 
The  comfort  to  the  patient,  relieved  as  if  by  miracle  from  her  pain 
and  photophobia,  was  most  remarkable.  Unfortunately,  however, 
this  state  of  comparative  happiness  lasted  from  twelve  to  fourteen 


THE  SEXUAL  EPOCH  OF  THE  MENARCHE.  161 

weeks  only,  after  which,  in  spite  of  everything  that  was  tried,  there 
was  no  further  recurrence  of  menstruation,  and  the  condition  of  the 
eyes  relapsed  to  what  had  existed  for  thirteen  years.  In  other  cases 
described  by  Mo  or  en  the  amenorrhoea  was  complicated  with  dis- 
seminated choroiditis  and  with  posterior  sclero-choroiditis. 

Beer  reports  a  case  of  retrobulbar  neuritis  occurring  with  amenor- 
rhoea, consequent  on  infantile  aplasia  of  the  uterus.  An  interesting- 
case  was  recorded  by  Dunn  of  a  girl  fifteen  years  of  age,  who  had 
not  yet  begun  to  menstruate,  and  who  suffered  from  interstitial 
keratitis,  with  severe  photophobia.  The  ocular  symptoms  vanished 
with  extreme  rapidity  as  soon  as  menstruation  first  appeared. 
Napier  observed  complete  blindness,  without  discernible  anatomical 
cause,  associated  with  amenorrhcea  of  sudden  onset ;  the  amaurosis 
disappeared  as  soon  as  menstruation  was  re-established. 

Striking  and  manifold  are  the  disturbances  of  the  nervous  system 
which  may  be  caused  by  amenorrhoea,  ranging  from  increased  irri- 
tability, hyperaesthesia  of  various  nerve  tracts,  neuralgia,  and  the 
like,  to  severe  psychoses. 

Barnes  reports  a  case  of  mental  disturbance  consequent  upon 
amenorrhoea  in  a  woman  twenty-seven  years  of  age,  who  had  begun 
to  menstruate  when  sixteen  years  old,  and  in  whom  the  menses 
had  been  suppressed  a  year  earlier  when  she  was  informed  of  the 
sudden  death  of  her  father.  From  that  time  a  progressively  increas- 
ing weakness  of  the  mind  was  observed.  In  a  case  recorded  by 
Macnaughton  Jones  the  mental  depression  consequent  on  amenor- 
rhcea was  so  great  that  it  led  to  an  attempt  at  suicide. 

Lawrence  observed  in  young  girls  who  from  any  cause  suffered 
from  amenorrhoea,  that  an  increased  pigmentation  of  the  skin  some- 
times occurred,  analogous  to  that  met  with  in  Addison's  disease. 
This  amenorrhceic  pigmentation  he  compares  to  the  chloasma  that 
is  seen  in  pregnant  women. 

By  menorrhagia  we  understand  the  occurrence  of  typical  dis- 
charges of  blood  from  the  uterus,  occurring  at  more  or  less  regular 
intervals  and  differing  from  normal  menstruation  in  respect  either 
of  the  greater  intensity  or  of  the  longer  duration  of  the  haemorrhage  ; 
whereas  by  metrorrhagia  we  understand  the  occurrence  of  atypical 
discharge  of  blood  from  the  uterus,  which  is  related  to  menstruation 
neither  in  respect  to  its  causation  nor  in  respect  to  the  time  of  its 
appearance. 

Menorrhagia  may  be  due  to  local  changes  in  the  genital  organs, 
to  organic  diseases  of  other  organs,  and  to  general  diseases. 

Local  changes  which  may  give  rise  to  menorrhagia  are,  active 
hyperaemia  and  passive  hyperaemia  (hyperaemia  from  engorgement) 
of  the  genital  organs,  such  hyperaemia  being  itself  due  to  sexual  ex- 

II 


162  THE  SEXUAL  LIFE  OF  WOMAN. 

citement,  especially  when  ungratified,  to  violent  physical  exercise,  or 
to  chill  during  menstruation ;  menorrhagia  is  also  liable  to  occur 
when  the  abdominal  circulation  is  disturbed  by  extreme  obesity  or  by 
the  presence  of  tumors,  also  in  connection  with  endometritis,  uterine 
myomata,  erosions  of  the  cervix,  etc.  Diseases  of  organs  other 
than  those  belonging  to  the  reproductive  system  which  are  espe- 
cially likely  to  give  rise  to  severe  bleeding  are,  disease  of  the  heart, 
such  as  valvular  incompetence,  lung  disease,  and  nephritis.  General 
diseases  in  which  menorrhagia  may  occur  are,  anaemia,  chlorosis, 
haemophilia,  scurvy,  scarlatina,  cholera,  smallpox,  influenza,  and 
obesity. 

Through  severe  loss  of  blood  in  menorrhagia,  whether  the  bleed- 
ing be  sudden  and  profuse  or  more  moderate  but  long  continued,  a 
condition  of  chronic  anaemia  results,  with  all  its  threatening  conse- 
quences to  the  health  and  the  life  of  the  woman  affected.  She  be-, 
comes  pale  and  weak,  unfitted  for  any  great  physical  or  mental 
exertion,  and  is  liable  to  attacks  of  cardiac  enfeeblement  and  to 
fainting  fits ;  in  some  cases  degenerative  changes  ensue  in  the  cardiac 
muscle. 

Dysmenorrhoea  is  characterized  by  severe  pain  occurring  before, 
during,  and  after  menstruation.  The  pain  is  caused  either  by  abnor- 
mally powerful  contractions  of  the  uterus  or  else  by  abnormal  sen- 
sitiveness of  that  organ.  Abnormally  powerful  contractions  are 
caused  by  various  mechanical  hindrances  to  the  normal  processes  of 
menstruation  ;  abnormal  sensitiveness  is  due  to  inflammatory  and  con- 
gestive states  of  the  uterus  and  its  annexa  or  to  a  general  increase 
of  nervous  sensibility. 

Schanta,  therefore,  distinguishes  a  mechanical,  an  inflammatory, 
and  a  nervous  form  of  dysmenorrhoea.  Mechanical  dysmenorrhoea 
is  most  frequently  due  to  stenosis  or  flexion  of  the  canal  of  the 
cervix  in  some  part  of  its  course  from  the  internal  to  the  external 
os,  dependent  upon  malformation  or  flexion  of  the  uterus,  hyper- 
plasia  of  the  mucous  membrane,  chronic  metritis,  scarring  resulting 
from  operative  procedures,  uterine  polypi,  etc.  In  inflammatory 
•dysmenorrhoea  we  have  to  do  "  either  .with  an  inflammatory  pro- 
cess or  with  excessive  tension  of  the  intrapelvic  organs,  dependent 
upon  abnormal  distension  of  their  blood  vessels."  To  the  same 
category  belong  ovarian  dysmenorrhoea,  and  dysmenorrhoea  due 
to  inflammatory  changes  in  the  Fallopian  tubes  and  to  pelvic  peri- 
tonitis. In  nervous  dysmenorrhcea,  no  anatomical  cause  is  apparent, 
but  the  uterine  contractions  normally  occurring  during  menstrua- 
tion, and  the  normal  congestive  distension  of  the  intrapelvic  organs 
at  that  period,  become  extremely  painful,  in  consequence  of  a 
morbid  increase  in  the  sensibility  of  the  nervous  system. 


THE  SEXUAL  EPOCH  OF  THE  MENARCHE.  163 

The  influence  of  dysmenorrhoea  on  the  general  condition  of  the 
woman  suffering  from  it  is  often  a  very  potent  one. 

The  normal  undulatory  course  of  the  bodily  temperature — which 
as  Reinl  has  shown,  undergoes  a  gradual  rise  until  shortly  before 
the  appearance  of  the  menstrual  flow,  gradually  falls  during  men- 
struation, and  continues  to  fall  for  a  time  after  menstruation  is  over 
—  undergoes  a  change  in  cases  of  dysmenorrhoea  due  to  anteflexion 
of  the  uterus,  parametritis,  or  salpingitis,  inasmuch  as  in  these  cases 
the  acme  of  the  temperature  curve  is  reached  actually  during  men- 
struation and  the  decline  of  temperature  comes,  not  at  the  commence- 
ment of  the  menstrual  flow,  but  often  only  after  the  flow  has  ceased. 
The  curve  of  blood  pressure  and  the  curve  indicating  the  excretion 
of  urea  are  similarly  affected  in  these  cases. 

As  symptoms  in  other  organs  occurring  in  cases  of  dysmenorrhcea 
Schauta  mentions  "  sensations  of  heat,  coldness  of  the  feet,  retching 
and  vomiting,  cramps  of  the  stomach  and  of  the  voluntary  muscles, 
general  disorders  of  nutrition,  loss  of  appetite,  strangury,  con- 
stipation, dyspepsia,  headache,  and  finally  hysteria.  As  symptoms 
of  the  latter  affection  we  may  notice,  anaesthesia,  hyperaethesia  of 
certain  parts  of  the  abdomen,  attacks  of  cramp,  paralysis,  uterine 
cough,  hiccough,  spasm  of  the  glottis,  epileptiform  seizures.  The 
repeated  severe  attacks  of  pain  may  seriously  disturb  the  nervous 
system,  leading  to  the  appearance  of  general  neuroses  and  psychoses. 
Frequently  we  observe,  as  a  peculiar  accompaniment  of  dysmenor- 
rhcea, changes  in  the  fulness  of  the  blood  vessels  of  the  face  and 
also  in  other  regions  of  the  skin,  in  consequence  of  vascular  para- 
lysis. In  other  cases,  actual  effusion  of  blood  occurs,  and,  as  a  sequel 
of  this,  deposits  of  pigment ;  and  the  semicircles  beneath  the  eyes 
may  become  so  dark  as  to  look  as  if  they  had  been  artificially  tinted 
(Macnaughton  Jones).  In  one  case,  during  menstruation  periodic 
swelling  of  the  gums  was  observed  (Regnicr).  Finally,  in  associa- 
tion with  dysmenorrhcea,  various  forms  of  neuralgia,  changes  in 
refraction,  and  slight  attacks  of  neuritis  and  retinitis  may  occur." 

One  of  the  commonest  symptoms  and  sequelae  is  headache,  some- 
times in  the  form  of  hemicrania,  which  may  be  associated  with 
dyspeptic  manifestations,  sometimes  diffused  over  the  whole  surface 
of  the  skull. 

Dyspepsia  is  a  very  frequent  associate  of  dysmenorrhoea.  Thus 
we  meet  with  pain  and  tenderness  in  the  gastric  region,  nausea, 
vomiting,  and  also  cardialgia.  Sometimes  the  liver  becomes  en- 
larged and  tender  on  pressure ;  in  many  cases  also  jaundice  is 
witnessed. 

Gcbhard  refers  to  another  phenomenon  which  may  be  classed 
under  the  head  of  dysmenorrhcea,  from  the  character  of  the  pain 


164  THE  SEXUAL  LIFE  OF  WOMAN. 

that  is  experienced,  even  though  this  pain  is  not  felt  at  the  men- 
strual periods,  but  in  the  intermenstrual  epoch.  This  is  the  so- 
called  intermediate  dysmenorrhoea  (intermenstrual  pain,  Ger. 
Mittelschmers).  In  the  character  of  the  localized  pain,  interme- 
diate dysmenorrhoea  closely  resembles  ordinary  dysmenorrhoea ;  it 
recurs  often  with  precise  regularity  on  certain  days  during  the  inter- 
menstrual interval.  Croom  distinguishes  three  forms  of  intermediate 
dysmenorrhoea ;  that  in  which  there  is  no  discharge  at  all  from  the 
uterus,  that  in  which  there  is  a  sanguineous  discharge,  and  that  in 
which  there  is  a  clear  watery  discharge.  The  first  form  he  attributes 
to  asynchronism  in  the  processes  of  ovulation  and  menstruation  j, 
the  second  form,  to  endometritis  with  disintegration  of  the  mucou? 
membrane ;  the  third,  to  a  kind  of  hydrops  tubae  profluens  (profluent- 
dropsy  of  the  Fallopian  tubes  —  hydrosalpinx  in  which  the  fluid 
accumulates  in  the  tube,  and  at  a  certain  stage  of  its  accumulation 
flows  into  the  uterus).  Cases  of  intermediate  dysmenorrhoea  are 
somewhat  rare,  if  we  eliminate  the  cases  in  which  pains  occur  in 
the  intermenstrual  epoch  in  consequence  of  disease  of  the  uterine 
annexa.  Inflammatory  manifestations  may  be  discovered  in  nearly 
all  typical  cases  of  intermediate  dysmenorrhoea. 

Long-continued  dysmenorrhoea  may  give  rise  to  numerous  hys- 
terical troubles,  general  convulsive  seizures,  local  muscular  spasm 
and  paralysis,  hiccough,  spasm  of  the  glottis,  uterine  cough,  twitch- 
ing and  spasm  of  various  groups  of  voluntary  muscles.  In  some 
cases  we  see  fully  developed  epileptic  convulsions,  with  complete 
loss  of  consciousness  and  immobility  of  the  pupils.  Finally,  psy- 
choses may  arise  in  association  with  dysmenorrhoea. 

In  cases  of  pathological  changes  in  menstruation,  a  carefully  ar- 
ranged hygiene  at  the  menstrual  periods  is  of  importance  both  for 
prophylactic  and  for  therapeutic  purposes,  and  in  this  connection 
I  may  refer  to  what  I  have  written  in  the  section  on  Hygiene  during 
the  Menarche.  In  cases  of  dysmenorrhoea  a  certain  amount  of 
repose  and  precaution  are  needed  during  the  flow,  with  avoidance  of 
chill,  scrupulous  cleanliness,  and  regulation  of  the  bowels.  In  cases 
of  amenorrhcea  we  must  prescribe  attention  to  the  general  nutrition 
by  means  of  an  easily  digested  roborant  diet,  as  much  fresh  air  as 
possible,  and  systematic  bodily  exercise.  In  these  cases,  bicycling, 
lawn  tennis,  and  suitable  gymnastics  are  often  of  value ;  also  baths, 
in  the  form  of  warm  general  baths,  hot  sitz  baths,  and  hot  foot  baths. 

Vicarious  Menstruation. 

In  cases  in  which,  in  consequence  of  morbid  conditions  of  the 
uterus,  the  ovaries,  or  the  organism  as  a  whole,  the  menstrual  flow 
has  at  the  time  of  the  menarche  either  failed  entirely  to  appear  or 


THE  SEXUAL  EPOCH  OF  THE  MENARCHE.  165 

been  exceedingly  scanty,  haemorrhages  from  other  organs  have  since 
ancient  times  been  witnessed,  and  these  haemorrhages  have  been 
regarded  as  vicarious  menstruation.  The  congestion  that  occurs 
during  menstruation  is  not  limited  to  the  genital  organs,  and  when 
the  flow  of  blood  from  the  uterus  fails  to  occur,  the  organism  seeks 
another  outlet,  in  order  to  restore  the  disturbed  equilibrium  of  blood 
distribution,  and  vicarious  haemorrhages  take  place  from  the  mouth, 
the  nose,  the  intestines,  the  anus,  the  gums,  the  mammae,  the  ears, 
and  the  lungs;  or  haemorrhages  occur  in  the  brain,  the  nerves,  or 
the  eyes. 

Although  it  must  be  admitted  that  confusion  has  often  occurred 
between  vicarious  menstruation  and  haemorrhages  dependent  on 
pre-existing  genuine  organic  disease,  such  as  haemoptysis  due  to 
pulmonary  tuberculosis,  or  haematemesis  due  to  gastric  ulcer,  still  the 
existence  of  a  true  vicarious  menstruation  must  be  regarded  as  fully 
established. 

Thus,  F richer,  Fleischmann,  Obermeier,  Beigel,  Withrow,  Plyette, 
and  Parsons  observed  vicarious  epistaxis ;  Watson,  Decaisne,  Ede- 
bohls,  Fischel,  and  Secligmann,  vicarious  haematemesis ;  Franchi, 
Hotte,  Rat  gen,  Voigt,  and  Windmiiller,  vicarious  haemoptysis; 
Dunlap,  vicarious  gingival  haemorrhage  ;  Law  and  Petiteau,  vicarious 
otorrhagia ;  Heusinger  and  le  Fort,  vicarious  haemorrhages,  occur- 
ring variously  from  the  anus,  bladder,  hand,  ear,  nipple,  stomach, 
and  nose ;  Baumgarten,  vicarious  haemorrhage  from  the  vocal  cords 
and  trachea ;  Hahn,  from  the  bladder ;  Kerley,  in  the  thyroid  body ; 
Galleinairts,  in  the  eyes.  Puech  found,  in  the  cases  he  collected,  that 
vicarious  menstrual  haemorrhage  occurred  from  the  stomach  thirty- 
eight  times,  from  the  mammary  glands  twenty-five  times,  from  the 
lungs  twenty-four  times,  and  from  the  nasal  mucous  membrane 
eighteen  times.  In  all  the  cases  menstruation,  had  long  been  in 
abeyance. 

Regarding  vicarious  epistaxis,  especially  exact  observations  have 
been  published,  showing  the  mutual  relationship  between  the  genital 
and  the  nasal  mucous  membrane.  A  series  of  cases  has  been  re- 
corded by  Fliess.  In  one  of  these  a  remarkably  well-developed  girl 
of  fourteen,  who  complained  at  three-weekly  intervals  of  molimina, 
in  the  form  of  languor,  headache,  and  sacrache,  after  an  interval  of 
four  weeks  epistaxis  occurred  instead  of  the  expected  menstruation ; 
three  weeks  later  came  another  attack  of  epistaxis ;  and  finally,  after 
an  interval  of  seven  weeks,  came  the  first  menstruation,  which  hence- 
forward recurred  every  three  weeks.  In  another  case,  that  of  a 
girl  aged  fifteen,  menstruation  appeared  once ;  four  weeks  later  came 
an  attack  of  epistaxis  instead  of  menstruation,  and  these  attacks  of 
epistaxis  were  continually  repeated,  at  intervals  of  twenty-nine  days. 


166  THE  SEXUAL  LIFE  OF  WOMAN. 

in  place  of  menstruation,  until  finally  pregnancy  occurred.  During 
pregnancy  the  epistaxis  ceased,  to  recur  however  six  weeks  after 
parturition;  the  attacks  continued  for  eight  monthly  periods,  when 
they  ceased  finally  at  the  commencement  of  the  second  pregnancy. 

Other  similar  cases  are  known  in  which  epistaxis  recurred  with 
all  the  regularity  of  the  menstruation  it  replaced  during  pregnancy 
and  ceased  at  parturition.  Analogous  cases  occur  in  which  epistaxis 
has  persisted  during  pregnancy,  during  the  puerperium,  and  at  the 
climacteric  period,  replacing  the  physiologically  suppressed  men- 
strual flow.  Similarly  Licgois  has  observed  vicarious  haemoptysis 
during  pregnancy.  According  to  Bainngarten,  in  vicarious  epistaxis 
the  bleeding  almost  always  proceeds  from  the  region  of  the  carti- 
laginous septum,  and  may  become  very  violent ;  vicarious  haemorrhage 
from  the  larnyx  proceeds  from  the  true  and  false  vocal  cords. 
Tracheal  haemorrhage  is  a  much  rarer  occurrence. 

Analogous  to  these  cases  are  those  in  which  the  vicarious  haemor- 
rhages occur  after  removal  of  the  ovaries.  Thus  Tauffcr  in  one  case 
saw  epistaxis  replace  menstruation  after  this  operation.  Schmalfttss 
reports  a  case  in  which  a  woman  suffering  from  valvular  disease 
of  the  heart,  was  said  after  oophorectomy  to  have  had  almost 
daily  attacks  of  haemoptysis  and  epistaxis.  Glaevecke  found  in  the 
post-operative  history  of  forty-four  cases  of  oophorectomy  that  two 
patients  suffered  from  vicarious  haemorrhages.  The  last-quoted 
author  is  of  opinion  that  the  suppression  of  menstruation  resulting 
from  oophorectomy  rarely  leads  to  vicarious  haemorrhages,  and  that 
even  when  these  do  occur  they  are  so  inconsiderable  in  amount  as 
to  have  no  practical  significance. 

Qnain  records  the  case  of  a  woman  aged  thirty-three,  in  whom 
uterus  and  ovaries  were  absent,  and  in  whom  for  two  years  epistaxis 
recurred  every  month  with  considerable  regularity. 

In  cases  in  which  menstruation  is  in  abeyance,  we  sometimes  wit- 
ness, instead  of  vicarious  haemorrhages,  the  occurrence  of  non-san- 
guineous vicarious  discharges  from  various  mucous  membranes. 
Thus,  vicarious  leucorrhcea  is  seen,  especially  in  chlorotic  patients, 
in  whom,  from  the  time  of  the  menarche  onward,  such  a  discharge 
may  occur  every  month,  instead  of  the  delayed  menstruation.  Simi- 
larly, vicarious  diarrhoea  and  vicarious  salivation  have  been  observed. 

THE  SEXUAL  IMPULSE. 

By  the  term  se.rnal  impulse,  we  understand  the  impulse  shared  by 
women  and  by  men  towards  intimate  physical  contact  and  sexual  in- 
tercourse with  individuals  of  the  opposite  sex.  In  the  child  this 
impulse  slumbers,  to  awaken  at  the  menarche  with  the  onset  of  pu- 


THE  SEXUAL  EPOCH  OF  THE-  MENARCHE.  167 

berty,  to  increase  slowly  at  first,  and  then  more  rapidly,  after  the 
manner  of  an  avalanche,  until  it  becomes  a  powerful  passion,  domi- 
nant throughout  the  active  sexual  life  of  the  woman,  and  it  may 
even  continue  far  beyond  this  period.  The  proper  aim  for  whose 
attainment  the  sexual  impulse  in  woman  strives  is  by  no  means 
(as  is  asserted  in  some  quarters)  the  fulfilment  of  "  the  impulse 
toward  motherhood,"  but  is  merely  the  complete  satisfaction  of 
sensual  passion  by  intercourse  with  the  male.  Still,  the  sexual  im- 
pulse is  often  satisfied  by  the  minor  degrees  of  sexual  gratification  in 
the  form  of  the  mutual  contact,  so  agreeable  to  the  sense  of  touch, 
of  portions  of  the  body,  and  even  by  the  play  of  imagination  and 
illusion  under  the  dominion  of  love.  Finally,  also,  love  amounts 
to  what  Buff  on,  the  celebrated  naturalist,  expressed  with  coarse 
incisiveness  in  the  phrase,  "  L'amour  c'est  le  frolement  de  deux 
intestins." 

In  the  sexually  mature  woman,  the  sexual  impulse  always  exists, 
though  its  strength  varies  in  accordance  with  individual  inheritance, 
with  physical  and  mental  condition,  and  with  external  circumstances, 
and  though  its  manifestation  may  be  repressed  by  force  of  will. 
The  sensation  of  the  sexual  impulse  in  a  maiden  during  the  years 
of  development  is  described  by  Goethe  in  a  masterly  manner  in  the 
verses.33 

"  Meirie  Ruh  ist  hin 

Mein  Herz  ist  schwer, 

Ich  finde  sie  nimmer 

Und  nimmermehr. 

Mein  Busen  drangt 

Sich  nach  ihm  hin, 

Ach,  diirft  ich  ihn  fassen 

Und  halten  ihn 

Und  kussen  ihn, 

So  wie  ich  wollt, 

An  seinen  Kussen 

Vergehen  sollt. 

A  resemblance  to  heat  or  rut  in  animals,  who  exhibit  the  sexual 
impulse  only  at  definite  periods,  those  at  which  the  ovules  ripen, 
is  manifested  in  females  of  the  human  species  only  in  so  far  as  there 

33  My  peace  is  lost, 
My  heart  is  heavy, 
I  find  it  never 
And  nevermore. 
My  bosom  presses 
Towards  him, 
Ah,  could  I  seize  him 
And  embrace  him, 
And  kiss  him, 
As  I  long  to  do, 
In  his  kisses 
I  should  pass  away. 


i68  THE  SEXUAL  LIFE  OF  WOMAN. 

is  during  menstruation  a  more  intense  sexual  sensibility;  but  the 
limitation  of  the  sexual  impulse  to  definite  periods,  and  its  close 
association  with  reproduction,  are  not  found  in  women.  Educa- 
tion and  morality  impose  artificial  limitations  on  the  sexual  im- 
pulse in  women,  whilst  nature  endows  this  impulse  with  a  coercive 
power,  a  fact  recognized  by  thinkers  of  all  times  and  all  peoples. 
Thus,  Buddha  wrote :  "  The  sexual  impulse  is  stronger  than  the 
ankus  with -which  the  wild  elephant  is  controlled,  it  is  hotter  than 
flame,  it  is  like  unto  an  arrow  driven  into  the  spirit  of  man."  In 
a  similar  sense  Luther  writes :  "  He  who  wishes  to  restrain  the 
impulse  of  nature  and  not  to  allow  it  free  play,  as  nature  will  and 
must,  what  does  he  do  but  this,  to  insist  that  nature  shall  not  be 
nature,  that  fire  shall  not  burn,  that  water  shall  not  wet,  that  man 
shall  neither  eat,  drink,  nor  sleep."  Schopenhaur  describes  the 
sexual  impulse  as  "  the  completest  outward  manifestation  of  the 
will  to  live,  the  concentration,  that  is  to  say,  of  all  wills.  * 
The  affirmation  of  the  will  to  live  concentrates  itself  in  the  act  of 
generation,  and  this  act  is  its  most  determined  expression."  Main- 
lander  in  his  Philosophy  of  Deliverance  makes  the  following  state- 
ment :  "  In  the  sexual  impulse  lies  the  centre  of  gravity  of  human 
life.  To  nothing  does  man  devote  a  more  earnest  attention  than  to 
the  business  of  generation,  and  in  the  pursuit  of  no  other  aim  does 
he  concentrate  the  intensity  of  his  will  in  so  striking  a  manner  as 
in  the  performance  of  the  act  of  generation."  Debay  similarly 
insists  on  the  strength  of  the  sexual  impulse,  saying :  '  The  union 
of  the  sexes  is  one  of  the  great  laws  of  nature;  to  that  law  men 
and  women  are  subordinated  as  completely  as  all  other  creatures, 
they  cannot  escape  its  operation." 

According  to  the  general  opinion,  the  sexual  impulse  is  not  so 
strongly  developed  in  women  as  it  is  in  men.  He  gar,  Litzniann, 
LombrosOj  P.  Midler,  and  many  others,  assume  that  the  sexual  sen- 
sibility of  women  is  less  than  that  of  men ;  Fitrbringer  is  inclined 
to  attribute  the  characteristic  of  sexual  frigidity  to  the  great  ma- 
jority of  German  wives.  I  do  not  believe  that  this  view,  of  the 
slight  intensity  of  the  sexual  impulse  in  women  in  general,  is  well 
grounded,  and  can  admit  only  this  much,  that  in  adolescent  girls 
who  are  inexperienced  in  sexual  matters,  the  sexual  impulse  is  less 
powerful  than  in  youths  of  the  same  age  who  have  undergone 
sexual  enlightenment.  From  the  moment  when  the  woman  also  has 
been  fully  enlightened  as  to  sexual  affairs,  and  has  actually  ex- 
perienced sexual  excitement,  her  impulse  toward  intimate  physical 
contact  and  toward  copulation  is  just  as  powerful  as  that  of  men. 
According,  however,  to  the  dominant  artificial  conditions,  man  as- 
sumes it  as  his  right  to  give  free  rein  to  his  sexual  desires  and 


THE  SEXUAL  EPOCH  OF  THE  MENARCHE.  169 

to  gratify  them  without  regard  to  consequences,  whereas  woman, 
narrowly  confined  within  the  boundaries  imposed  by  law  and  con- 
vention, cannot  so  readily  yield  to  her  inclination  in  the  direction 
of  physical  love,  and  must  forcibly  control  that  inclination.  More- 
over, a  powerful  check  on  the  free  indulgence  of  the  sexual  im- 
pulse is  imposed  on  woman  by  the  consequences  of  such  indulgence, 
consequences  which  exist  tor  woman  only. 

I  may  further  indicate  as  differential  characteristics,  that  in  woman 
the  sexual  impulse  is  more  accessible  to  voluntary  control  than  it 
is  in  man,  the  ardor  of  female  sexual  passion  is  more  readily  dimin- 
ished than  that  of  the  male ;  and  again  that  in  the  female  the  grati- 
fication of  the  sexual  impulse  is  less  narrowly  restricted  than  in  the 
male.  Excessive  sexual  gratification  on  the  one  hand  and  suppres- 
sion of  sexual  desire  on  the  other  are,  generally  speaking,  less  harm- 
ful to  the  female  organism  than  to  the  male.  In  these  differentiae  is 
to  be  found,  in  my  opinion,  the  influence  which  determines  the  type 
of  sexuality  in  the  respective  sexes. 

The  following  account  is  given  by  Havelock  Ellis  of  the  differential 
characters  of  the  sexual  impulse  in  the  female  :  "In  courtship,  woman 
plays  a  more  passive  part  than  man;  in  woman  the  physiological 
mechanism  of  the  sexual  processes  is  more  complicated,  and  the  or- 
gasm develops  more  deliberately ;  the  sexual  impulse  in  woman  needs 
more  frequently  to  be  actively  stimulated ;  the  culmination  of  sexual 
activity  is  attained  later  in  the  life  of  woman  than  in  the  life  of  man, 
the  strength  of  sexual  desire  in  woman  becomes  greater  after  she  has 
entered  upon  regular  sexual  intercourse,  women  bear  sexual  excesses 
better  than  men ;  the  sexual  sphere  is  larger  and  more  widely  dif- 
fused in  women  than  it  is  in  men ;  finally,  in  woman  the  sexual  im- 
pulse exhibits  a  distinct  tendency  to  periodic  exacerbations,  and  it 
is  in  any  case  much  more  variable  than  in  man."  The  same  author, 
who  has  published  several  notable  biological  studies  on  subjects 
connected  with  sex,  maintains  that  the  source  of  erotic  pleasure  in 
the  case  of  the  male  lies  in  activity,  but  in  the  female  in  the  passive 
state,  in  the  experience  of  compulsion,  and  he  holds  that  sexual 
subordination  is  a  necessary  element  in  the  sexual  enjoyment  of 
women. 

Hegar  maintains  that  under  the  term  sexual  impulse  two  distinct 
conceptions  are  confounded :  First,  the  impulse  toward  copulation, 
the  desire  of  carnal  union  with  a  member  of  the  opposite  sex; 
secondly,  the  impulse  toward  reproduction,  the  desire  for  children. 
At  the  same  time,  this  author  admits  that  it  is  questionable  if  we 
can  properly  speak  of  an  impulse  toward  reproduction,  when  repro- 
duction is  merely  a  consequence  of  copulation  ;  in  the  case  of  civilized 
man,  at  any  rate,  so  much  reflection  is  connected  with  the  idea  of 


170  THE  SEXUAL  LIFE  OF  WOMAN. 

reproduction  that  it  can  hardly  be  proper  to  speak  of  anything  of 
the  nature  of  an  impulse.  In  the  case  of  woman,  the  expression  is 
less  unsuitable,  since  in  woman  special  organs  exist  for  the  main- 
tenance of  the  ovum  after  fertilization,  and  these  organs  may.  perhaps 
lead  to  the  production  of  this  peculiar  form  of  mental  activity. 

According  to  Darwin,  a  comparatively  less  intensity  of  sexual  desire 
is  common  to  the  females  of  all  species  of  the  animal  kingdom. 
The  female  demands  a  prolonged  courtship,  and  often  endeavors 
for  a  considerable  time  to  elude  the  male.  In  the  lowest  classes  of 
the  animal  kingdom  the  female  leads  a  separate  existence  as  soon  as 
she  has  been  fertilized  by  the  male,  the  sexual  functions  being  thus 
subordinated  to  the  maternal.  Among  birds  at  the  pairing  season 
the  male  is  always  the  more  passionate  and  active  of  the  two,  whilst 
the  female  commonly  remains  passive  and  occupies  herself  in  build- 
ing the  nest.  Among  mammals,  it  is  difficult  to  determine  whether 
sexual  feeling  is  stronger  in  the  female  or  in  the  male;  but  it  is 
certain  that  sexual  relations  are  seldom  long  lasting,  they  continue 
in  most  cases  only  during  the  period  of  heat  or  rut,  and  at  most 
only  till  the  birth  of  the  young. 

From  these  phenomena  witnessed  in  the  animal  kingdom,  many 
naturalists  have  concluded  that  in  females  of  the  human  species  also, 
sexual  sensibility  and  the  intensity  of  the  sexual  impulse  are  less 
than  in  the  males,  and  even  that  the  sexual  sense  in  general  is  but 
little  developed  in  the  female  sex,  or  sometimes  entirely  wanting. 
The  complicated  apparatus  which  the  primary  and  secondary  sexual 
characters  of  the  female  combine  to  make  up,  exists,  according  to 
this  view,  not  for  the  gratification  of  the  sexual  impulse,  but  for  the 
fulfilment  of  the  function  of  motherhood.  "  Love  in  women,"  says 
Lombroso,  "  is  in  its  fundamental  nature  no  more  than  a  secondary 
character  of  motherhood,  and  all  the  feelings  of  affection  that  bind 
woman  to  man  arise,  not  from  sexual  impulses,  but  from  the  instincts, 
acquired  by  adaptation,  of  subordination  and  self-surrender." 

Mantegazza  lays  stress  on  the  fact  that  in  the  female,  sexual  de- 
sire is  very  rarely  accompanied  by  pains  analogous  to  those  which 
occur  in  man,  in  whom  sexual  excitement  manifests  itself  in  painful 
tension  of  the  testicle  and  the  seminal  vesicles,  or  in  spasmodic, 
long-continued  priapism. 

Sergi  writes  to  Lombroso:  "  The  normal  woman  loves  to  be  flat- 
tered and  wooed  by  man,  but  yields  herself  to  his  sexual  desires  only 
like  an  animal  at  the  sacrifice.  It  is  well  known  how  much  pains 
must  be  taken,  how  many  caresses  must  be  expended,  before  a  woman 
will  yield  with  pleasure  to  a  man's  desires,  and  will  share  his  sexual 
passion.  Without  the  employment  of  these  means,  a  woman  remains 
cold  and  gives  as  little  satisfaction  as  she  feels.  There  are  girls 


THE  SEXUAL  EPOCH  OF  THE  MENARCHE.  171 

who  are  quite  obtuse  to  the  joys  of  love,  and  either  resist  energetically 
a  man's  approaches,  or  yield  to  him  passively,  without  ardor  and 
without  enthusiasm.  It  is  well  known,  also,  that  among  the  lower 
races  of  mankind,  means  are  employed  to  stimulate  the  sexual  sen- 
sibility in  women,  means  that  seem  to  us  to  amount  to  torture ;  and 
that  the  male,  with  the  same  end  in  view,  undergoes  the  most  pain- 
ful operations,  from  which  it  is  apparent  that  the  slight  sexual 
sensibility  of  women  in  these  lower  grades  of  civilization  is  fully 
recognized."  And  again :  "  If  a  normal  woman  marries  for  love, 
she  hides  that  love  deep  in  her  heart,  and  even  on  the  wedding-day 
exhibits  no  great  sexual  excitement ;  she  often  complains  later  that 
in  her  husband  the  love-fervor  of  the  first  days  still  continues;  the 
very  moderate  sexual  needs  of  the  wife  form  a  natural  and  most 
valuable  check  to  the  much  more  powerful  passion  of  the  male." 

Saint  Prospcre  expresses  himself  to  a  similar  effect:  "Women 
do  not  fall  in  consequence  of  the  excessive  power  of  the  senses  — 
in  this  domain  they  are  overlords,  in  striking  contrast  to  men,  whose 
weakest  side  is  here.  It  is  not  by  means  of  the  senses  that  a  woman 
is  to  be  overcome ;  her  weakness  lies  elsewhere  —  in  her  heart,  in 
her  vanity."  And  de  Lambert  wrote  the  epigram,  "  Women  play 
with  love,  and  yield  themselves  to  love,  but  they  do  not  abandon 
themselves  to  love." 

Well  known  also  is  the  saying  of  Dante: 

"  We  know  how  speedily  in  women  the  fire  of  love  is  consumed 
Unless  eye  and  hand  continually  supply  it  with  fresh  fuel." 

On  the  other  hand,  it  is  asserted  in  the  laws  of  the  Hindus  that 
sexual  desire  in  women  can  as  little  be  satisfied  or  fed  full  as  a  de- 
vouring fire  can  be  fed  full  of  combustible  materials,  or  as  the  ocean 
can  be  overfilled  by  the  rivers  that  pour  their  waters  into  it. 

Lombroso  finds  a  proof  of  the  sexual  indifference  of  women  and 
of  the  greater  sexual  needs  of  man,  in  the  existence  of  prostitution, 
with  which  can  be  contrasted  the  existence  only  among  the  degener- 
ate classes  (both  rich  and  poor)  of  a  small  group  of  male  prosti- 
tutes (alfons,  souteneurs).  This  author  also  refers  to  the  rarity  and 
uniformity  in  women  of  the  sexual  psychoses  so  frequent  in  men, 
as  indications  of  the  minor  intensity  of  sexual  desire  in  the  former ; 
and  he  refers  also  to  a  series  of  facts,  as  for  instance,  to  the  occur- 
rence of  platonic  love,  which,  though  indeed  often  hypocritical,  has 
a  real  existence  more  often  in  the  female  sex  than  in  the  male;  to 
the  long-enduring  chastity  of  girls,  and  to  vows  of  chastity, 
which  are  rarely  made  except  by  females ;  moreover,  the  ready  adap- 
tation of  women  to  polygamy,  as  well  as  their  scrupulous  observance 
of  monogamy,  which  latter  for  the  male  is  nominal  rather  than 


172  THE  SEXUAL  LIFE  OF  WOMAN". 

actual.  If  in  general  the  opposite  view  concerning  women  prevails, 
this  is  ascribed  by  Lombroso  to  the  fact,  that  love  is  the  most  im- 
portant circumstance  in  a  woman's  life.  The  reason  therefore,  how- 
ever, is  to  be  found,  not  in  the  erotic  sphere,  but  in  the  desire  for  the 
satisfaction  of  the  maternal  instinct,  and  in  a  woman's  need  for  pro- 
tection. A  celebrated  accoucheur,  Giordano,  has  remarked :  "  Man 
loves  woman  for  the  sake  of  the  vulva ;  what  woman  loves  in  man  is 
the  husband  and  the  father.  Comprehensively  we  may  express  the 
matter  by  saying  that  woman  has  less  eroticism  and  more  sexuality." 

As  a  rule,  remarks  Erb,  it  is  believed  that  the  sexual  impulse  is 
less  intense  in  women  than  in  men.  This  is  true  enough,  he  writes, 
as  regards  youthful  and  virgin  individuals,  who  have  not  yet  come 
into  intimate  contact  with  men,  and  in  whom  sexual  desire  and 
sensibility  have  not  yet  been  directly  excited;  later,  however,  when 
sexual  intercourse  has  been  begun,  a  change  usually  takes  place,  and 
the  sexual  needs  become  active  in  women  also,  and  demand  satisfac- 
tion. It  is  well  known  that  not  a  few  women  experience  powerful 
and  uncontrolled  sensual  inclinations,  just  like  those  of  men.  On 
the  other  hand,  we  must  insist  that  quite  a  large  number  of  women 
possess  the  so-called  naturae  frigidae,  and  have  no  sensual  inclination 
to  sexual  intercourse,  to  which  they  are  either  indifferent,  or  in 
some  cases  strongly  averse,  even  regarding  it  with  horror.  This  lack 
of  the  sexual  sense  in  women,  is  especially  common  in  hysterical  sub- 
jects, and  Erb  reports  that  he  has  encountered  quite  a  large  number 
of  cases  of  this  character.  Whether  in  quite  healthy  women  with 
normal  sexual  impulse,  complete  abstinence  from  sexual  intercourse, 
too  often  compulsory  but  sometimes  voluntarily  undertaken,  is  harm- 
ful in  its  consequences  —  this,  says  Erb,  is  a  question  very  difficult 
to  answer.  Many  such  unfortunate  women  have  assured  him  that 
they  suffered  severely  in  consequence  of  their  enforced  continence ; 
the  majority  of  these  became  neurasthenic  or  hysterical.  The  com- 
plication of  purely  physical  influences  with  mental  influences,  in- 
creases the  difficulty  of  the  problem.  Neurologists  have  observed 
women  on  whom  continence  was  forced  either  during  marriage  or 
after  its  dissolution,  who  thereupon  fell  into  a  state  of  severe  ner- 
vous exhaustion  or  nervous  excitement,  or  suffered  from  threatening 
or  even  actually  developed  psychoses.  That  sexual  abstinence  is 
"  absolutely  harmless,"  as  moralists  and  many  physicians  would  so 
gladly  believe,  appears  to  Erb  a  quite  unwarrantable  assumption. 

"  In  the  processes  of  reproduction,"  continues  Erb  in  his  discus- 
sion of  this  subject,  "  woman  is  the  principal  sufferer.  With  inhuman 
cruelty,  nature  has  condemned  woman  to  a  far  more  difficult  role 
than  man  in  the  intercourse  of  the  sexes  and  in  the  preservation  of 
the  species;  she  is  overpowered  and  forced  by  man,  she  is  com- 


173 

pelled  to  make  the  most  severe  sacrifices  for  the  sake  of  the  new 
generation,  first  when  it  is  germinating  within  her  womb,  and  later 
when  it  is  entrusted  to  her  care ;  and  only  too  frequently  she  fails  to 
find  the  respect  and  protection  due  to  her  for  the  performance  of 
these  functions !  Compared  with  the  sacrifices  made  by  woman,  the 
temporary  continence  which  is  all  that  is  demanded  from  man  will 
be  admitted  to  be  a  small  matter !  It  is  fortunate  that  as  a  rule  the 
young  woman  who  has  never  come  into  intimate  contact  with  the 
male,  appears  to  be  endowed  by  nature  with  a  relatively  weak  sexual 
impulse!  This  unequal  and  unjust  distribution  of  the  male  and 
female  roles  on  the  part  of  nature  may  be  regretted,  but  it  cannot 
be  altered." 

The  modern  advocates  of  the  rights  of  women,  who  demand  that 
in  the  sexual  sphere  also,  woman  should  receive  emancipation,  op- 
pose the  view  that  in  the  male  the  sexual  impulse  is  stronger  than  in 
the  female,  and  also  the  view  that  whilst  in  the  male  the  impulse  is 
simply  one  toward  sexual  congress,  in  the  female  the  determining 
motive  to  intercourse  is  furnished  by  the  desire  for  motherhood. 
They  complain  of  "  the  perverse  repression  in  woman  of  the  sexual 
impulse  and  its  physiological  gratification,"  since  sexual  energy  and 
sexual  sensibility  are  equal  in  intensity  and  identical  in  quality  in  the 
female  and  in  the  male.  Thus,  Johanna  Elberskirchcn  writes 
(Die  Sexualempfindung  bei  Weib  und  Mann  —  Sexual  Sensation 
in  Woman  and  Man)  :  "  Body  and  soul,*the  whole  being  is  subor- 
dinated to  a  single  powerful  feeling  and  impulse,  a  single  will  flows 
through  nerves  and  blood,  forcing  and  driving  the  female  toward 
the  male  with  irresistible  power;  the  yearning,  the  longing  for  the 
relief  of  sexual  tension,  the  craving  for  the  euphoria  and  fleshly 
delight  that  dominate  the  whole  personality.  And  this  elementary 
sexual  longing  it  is  that  clouds  the  woman's  brain,  that  drives  her 
into  the  man's  arms,  that  leads  her  to  forget  all  the  shame  threaten- 
ing her  and  her  child,  that  brings  her  to  sexual  union  —  not  the 
longing  for  a  child,  not  the  so-called  impulse  to  motherhood."  And 
again :  "  Woman  yearns  for  love,  all  her  love-organs  cry  out  for 
love,  soul  and  body  *  *  *.  We  do  not  long  only  for  the  rude 
sexual  act.  We  spiritualise  it  —  at  least  some  of  us  do  so ;  at  any 
rate  we  individualize  it.  It  is  one  particular  man  whom  we  desire, 
he  alone  can  still  our  longing,  our  bodily  and  mental  hunger  for 
love.  He  satisfies  us  with  all  his  love-affinities."  Naturally,  also,  the 
consequence  is  deduced,  "  a  free  course  must  be  given  to  sexual 
sensation  in  women,  and  to  the  satisfaction  of  sexual  desire,  within 
physiological  limits,  within  the  bounds  of  physiological  necessity." 

Lowenfcld  asserts  that  in  the  life  of  woman  the  sexual  functions 
play  a  comparatively  much  greater  part  than  in  the  life  of  man, 


174  THE  SEXUAL  LIFE  OF  WOMAN. 

woman's  thoughts  and  feelings  are,  that  is  to  say,  much  more  power- 
fully influenced  by  sexual  matters  than  those  of  men ;  but  none  the 
less  he  is  of  opinion  that  in  the  normal  woman  the  desire  for  sexual 
satisfaction  is  on  the  average  less  keen  than  in  the  normal  man.  Dis- 
tinctly greater  in  woman  is  the  erotic  element  only,  the  need  to  love 
and  to  be  loved  after  an  ideal  manner,  which  is  excited  by  the  repro- 
ductive glands  just  as  much  as  is  the  simple  sensual  desire.  Very 
frequently,  manifestations  of  this  ideal  need  are  erroneously  at- 
tributed to  the  sensual  impulse,  yet  this  latter  may  be  entirely  absent 
in  cases  in  which  the  erotic  element  is  strongly  developed.  Accord- 
ing to  Lowenfeld,  the  sexual  impulse  is  altogether  wanting  in  young 
girls  before  the  time  of  puberty,  and  in  elderly  women  (in  the  case 
of  the  latter  we  consider  this  assertion  most  questionable)  ;  this  lack 
of  the  sexual  impulse  persists  in  girls  for  an  indeterminate  time  even 
after  puberty,  as  long  as  they  remain  free  from  all  experience  of 
sexual  stimulation.  In  this  respect  they  offer  a  notable  contrast  to 
males  of  the  same  age.  In  normal  girls,  according  to  the  same  au- 
thor, erotic  dreams  and  similar  occurrences  are  entirely  wanting,  and 
specific  sexual  sensations  therefore  remain  absolutely  unknown  to 
them ;  hence  it  follows  that  the  sexual  impulse  cannot,  properly  speak- 
ing, arise  in  such  individuals,  and  in  so  far  as  they  experience  any 
desire  for  sexual  intercourse  it  can  only  take  the  form  of  a  craving 
for  some  enjoyment,  the  nature  of  which  is  entirely  unknown.  The 
absolute  lack  of  the  sexual  impulse  (complete  frigidity)  persists, 
according  to  Lo'wcnfcld,  in  a  not  inconsiderable  proportion  of  women 
even  after  their  introduction  to  sexual  intercourse  —  Efforts  esti- 
mates that  such  complete  frigidity  is  permanent  in  10  per  cent,  of  all 
women  —  and  in  a  still  greater  proportion  of  women  the  sensual 
impulse  never  exceeds  a  certain  minimal  intensity  (partial  frigidity). 
It  is  probable  that  in  the  higher  classes  of  society,  inherited  predis- 
position, education,  and  perhaps  also  higher  intelligence,  combine 
to  diminish  the  intensity  of  the  sexual  impulse.  In  contrast  with 
these  women  of  frigid  temperament,  however,  we  meet  with  women, 
certainly  in  very  limited  numbers,  whose  sexual  passions  are  ex- 
tremely powerful,  and  whose  needs  no  man  can  satisfy. 

Hcgar,  who  considers  that  the  sexual  impulse  in  women  is  seldom 
very  powerful,  draws  the  following  conclusions  in  respect  of  the 
influence  of  sexual  gratification,  on  the  one  hand,  or  of  continence, 
on  the  other,  on  the  duration  of  life  and  on  physical  and  mental 
health  :  "As  far  as  comparisons  between  married  women  and  women 
vowed  to  celibacy  (nuns  and  members  of  other  celibate  religious 
orders)  justify  any  conclusion,  sexual  activity  and  inactivity,  respec- 
tively, would  appear  to  have  little  influence  on  the  duration  of 
life.  Comparisons  between  married  and  single  women  show, 


THE  SEXUAL  EPOCH  OF  THE  MENARCHE.  175 

indeed,  that  the  gratification  of  the  sexual  impulse  and  the  processes 
of  reproduction  are  distinctly  injurious  when  experienced  before  the 
attainment  of  complete  sexual  maturity.  In  married  women  up  to 
the  age  of  thirty,  in  some  countries  even  up  to  the  age  of  forty,  the 
mortality  is  greater  than  in  unmarried  women.  The  notably  smaller 
mortality  of  married  women,  as  compared  with  unmarried,  after  the 
age  of  forty,  is  usually  explained  as  the  result  of  the  complete  ful- 
filment of  the  genital  functions.  It  may,  however,  find  a  truer 
explanation  in  the  selection  effected  by  marriage,  especially  when 
we  take  into  consideration  that  from  the  women  thus  selected  the 
weaker  individuals  have  been  previously  weeded  out  by  the  processes 
of  reproduction. 

"  The  lesser  mortality  of  married  men  from  the  age  of  twenty 
upwards  is  to  be  explained  by  the  selection  of  the  fit  which  occurs 
in  marriage,  by  the  smaller  proportion  of  marriages  among  men 
engaged  in  hazardous  occupations,  and  by  the  deterioration  in  the 
quality  of  the  unmarried  which  results  from  emigration.  Still  the 
directly  favorable  influence  of  marriage  is  undeniable,  and,  no  doubt, 
the  ethical  factors  of  this  institution  have  a  beneficial  effect,  whereas 
the  gratification  of  the  sexual  impulse  hardly  enters  into  the  account. 

"  Suicide  is  certainly  very  little  dependent  upon  repression  of  the 
sexual  impulse,  since  all  the  motives  arising  out  of  the  affairs  of 
love  play  together  but  a  small  part  among  the  causes  of  suicide." 

"  The  beneficial  influence  of  marriage  in  the  prevention  of  insanity 
is  in  part  apparent  merely,  since,  in  the  selection  exercised  by  mar- 
riage, those  predisposed  to  mental  disorder,  and  those  in  whom  such 
disorder  has  already  manifested  itself,  are,  for  the  most  part,  already 
excluded.  Still,  as  regards  the  male  sex  at  any  rate,  the  beneficial 
influence  of  marriage  is  undeniable,  and  consists  principally  in  the 
favorable  ethical  factors  of  this  state.  In  women,  on  the  other 
hand,  the  advantage  of  marriage  is  doubtful,  since  the  nerve  centres 
and  the  nervous  system  as  a  whole  are  strongly  affected  by  the  proc- 
esses of  reproduction. 

"  Satyriasis,  nymphomania,  and  hysteria  are  in  no  way  dependent 
upon  the  repression  of  the  sexual  impulse. 

"Criminality  in  the  married  is  comparatively  less  common  than 
in  the  unmarried.  In  criminal  assaults  on  young  persons,  repressed 
sexual  impulse  plays  a  part. 

"  Chlorosis  is  not  in  any  way  dependent  on  repression  of  the 
sexual  impulse.  A  disease  apparently  analogous  to  chlorosis,  occur- 
ring in  unmarried  women  from  twenty  to  thirty  years  of  age,  is 
dependent  rather  on  mental  causes,  and  is  relieved  by  other 
means  than  marriage,  especially  by  suitable  occupation.  Marriage 
and  gestation  are  distinctly  injurious  in  cases  of  true  chlorosis. 


176  THE  SEXUAL  LIFE  OF  WOMAN. 

"  The  satisfaction  of  the  sexual  impulse,  and  still  more  gesta- 
tion, favor  in  women  the  origin  and  growth  of  tumors,  give  rise 
often  to  mechanical  disturbances,  and  open  the  way  for  the  invasion 
of  toxic  pathogenic  germs. 

"  Osteomalacia  occurs  only  in  parous  women." 

Moll  divides  the  sexual  impulse  into  two  components  :  The  impulse 
toward  intimate  contact  (in  a  sense  both  physical  and  mental)  with 
a  person  of  the  opposite  sex,  which  he  calls  the  contrectation-impulse 
(Kontrektationstrieb)  ;  and  the  impulse  to  bring  about  a  change  in 
the  genital  organs,  which  he  calls  the  detumescence-impulse 
(Detumessenstrieb}.  The  former  impulse  induces  intimate  physical 
and  mental  contact  between  the  two  persons  concerned,  the  latter 
impulse  induces  the  local  processes  of  copulation.  In  women,  detu- 
mescence  results  from  the  passing  off  of  local  swelling  and  the  release 
of  nervous  tension  in  the  genital  organs,  with  the  discharge  of  in- 
different glandular  secretions,  notably  the  secretion  of  Bartholin's 
glands,  and  perhaps  also  the  secretion  of  the  uterine  glands.  The 
intensity  of  the  detumescence-impulse  in  women  varies  greatly  in 
different  individuals,  these  variations  being  more  extensive  than 
those  occurring  in  the  male.  In  some  women  the  impulse  toward 
intimate  contact,  the  contrectation-impulse,  is  normal,  though  the 
detumescence-impulse  is  wholly  wanting  (vide  Dyspareunia). 

Runge  defines  the  sexual  impulse  as  the  impulse  which  brings  the 
sexes  together.  This  impulse  is  subservient  to  an  instinct,  namely 
the  instinct  of  reproduction ;  that  is  to  say,  the  sexual  impulse  in- 
duces the  individual  to  perform  actions  which  subserve  the  purpose 
of  reproduction  without  the  agent's  being  directly  or  chiefly  con- 
cerned with  this  purpose. 

The  sexual  impulse,  as  sensation,  perception,  and  impulse,  is, 
according  to  von  Krafft-Ebing,  a  function  of  the  cerebral  cortex; 
a  centre  for  the  sexual  sense  has  not  as  yet,  however,  been  localized. 
The  close  relations  which  obtain  between  the  sexual  life  and  the 
sense  of  smell  lead  to  the  supposition  that  the  sexual  and  the  olfac- 
tory spheres  of  the  cerebral  cortex  are  in  close  proximity  one  with 
the  other.  The  development  of  the  sexual  life  has  its  beginnings 
in  the  organic  sensations  of  the  developing  reproductive  glands. 
A  mutual  dependence  now  arises  between  the  cerebral  cortex  as 
place  of  origin  of  sensations  and  perceptions,  and  the  organs  of 
generation.  By  anatomico-physiological  processes  these  now  give 
rise  to  sexual  perceptions,  representations,  and  impulses.  The  cere- 
bral cortex,  by  apperceived  or  reproduced  sensuous  perceptions, 
influences  the  organs  of  generation.  This  influence  is  effected  by 
the  intermediation  of  the  centres  of  vascular  innervation  and  ejacu- 
lation, which  are  situated  in  the  lumbar  enlargement  of  the  spinal 


THE  SEXUAL  EPOCH  OF  THE  MENARCHE.  177 

cord,  and  are  certainly  in  close  proximity  one  with  the  other.     Both 
are  reflex  centres. 

The  psycho-physiological  process  embraced  in  the  conception  of 
the  sexual  impulse  is  according,  to  von  Krafft-Ebing  constituted  in 
the  following  manner : 

I.  Of  the  central  or  peripherally  aroused  perceptions. 

II.  Of  the  pleasurable  sensations  associated  with  these. 

Hence  arises  the  impulse  to  sexual  satisfaction  (libido  sexualis). 
This  impulse  becomes  stronger  in  proportion  as  cerebral  excitement, 
consequent  on  appropriate  perceptions  and  the  working  of  the  imagi- 
nation, strengthens  the  intensity  of  these  pleasurable  sensations.  If 
the  conditions  are  favorable  to  the  performance  of  the  sexual  act  by 
means  of  which  satisfaction  is  attained,  the  continually  increasing 
impulse  finds  expression  in  action ;  in  other  circumstances,  inhibitory 
perceptions  intervene,  sexual  excitement  diminishes,  the  activity  of 
the  centre  for  erection  is  inhibited,  and  the  sexual  act  itself  is  pre- 
vented. In  the  case  of  civilized  humanity  the  ready  action  of  such 
perceptions  for  the  inhibition  of  the  sexual  impulse  is  necessary 
and  decisive.  On  the  strength  of  the  impulsive  perceptions  the  con- 
stitution and  various  organic  processes  have  an  important  influence ; 
on  the  strength  of  the  inhibitory  perceptions,  education  and  the 
cultivation  of  self-control  are  powerfully  operative. 

In  addition  to  mental  influences,  all  forms  of  local  irritation  of 
the  sensory  nerves  of  the  female  genital  organs  and  adjacent  parts, 
by  internal  processes  or  external  friction,  serve  to  increase  the 
strength  of  the  sexual  impulse.  Among  internal  processes  which 
stimulate  the  erectile  centre  by  centripetal  impulses  must  be  in- 
cluded, the  stimulus  of  the  enlarged  graafian  follicle,  stasis  in  various 
vascular  areas  of  the  genital  organs  in  consequence  of  a  sedentary 
mode  of  life,  abdominal  plethora  from  excessive  consumption  of 
food  and  stimulating  drinks,  and  habitual  constipation.  External 
friction  may  be  in  the  form  of  intentional  manipulation,  but  it  may 
be  due  to  certain  bodily  attitudes  or  to  the  arrangement  of  the 
clothing. 

In  normally  constituted  individuals,  the  sexual  impulse  is  by  no 
means  constant  in  its  intensity.  Apart  from  the  temporary  indif- 
ference resulting  from  sexual  gratification,  and  apart  from  the  de- 
cline in  the  impulse  that  occurs  after  prolonged  continence,  ensuing 
after  a  certain  reactionary  intensity  of  desire  has  been  happily  over- 
come, the  mode  of  life  has  a  very  great  influence.  The  town-dweller, 
who  is  continually  reminded  of  sexual  matters,  and  continually 
solicited  to  sexual  intercourse,  is  in  any  case  more  subject  than  the 
countryman  to  sexual  excitement.  A  sedentary  and  sheltered  mode 
of  life,  a  chiefly  animal  diet,  the  free  use  of  alcohol  and  of  spices, 

12 


178  THE  SEXUAL  LIFE  OF  WOMAN. 

and  the  like,  have  a  stimulating  action  on  the  sexual  life.  In  the 
female,  the  sexual  impulse  is  stronger  just  after  menstruation.  In 
neuropathic  women  this  increase  of  excitement  may  occur  to  a 
pathological  degree.  Not  infrequently  also  in  the  climacteric  period, 
women  are  subject  to  sexual  excitement  due  to  pruritus,  especially  in 
those  neuropathically  predisposed.  M agnan  reports  the  case  of  a 
lady  who  was  subject  to  matutinal  accesses  of  intense  erethismus 
genitalis. "  The  same  author  writes  of  a  young  lady  who  since  pu- 
berty had  been  subject  to  continually  increasing  sexual  impulse, 
which  she  gratified  by  masturbation.  Gradually  it  came  to  pass 
that  the  sight  of  a  good-looking  man  produced  violent  sexual  ex- 
citement, and  on  these  occasions,  since  she  felt  herself  unable  to 
answer  for  her  own  conduct,  she  used  to  lock  herself  up  in  her  bed- 
room till  the  storm  had  passed  away.  Ultimately  she  surrendered 
herself  to  any  available  man  in  order  to  obtain  rest  from  her  tortur- 
ing desires,  but  neither  intercourse  nor  onanism  gave  her  relief, 
so  that  she  was  finally  sent  to  an  asylum. 

As  regards  pathological  increase  of  the  sexual  impulse,  hyper- 
aesthesia  sexualis,  the  constitution  of  the  individual  is,  according  to 
von  Krafft-Ebing  (Psychopathia  Sexualis),  of  great  importance.  He 
writes :  "  With  a  neuropathic  constitution,  a  pathological  increase 
of  sexual  desire  is  often  associated,  and  such  individuals  bear  for 
the  greater  part  of  their  life  the  heavy  burden  of  this  constitu- 
tionally anomalous  sexual  impulse.  The  intensity  of  the  sexual 
impulse  may  be  such  as  to  amount  to  an  organic  compulsion,  and 
the  freedom  of  the  will  may  thus  be  seriously  imperilled.  Non- 
satisfaction  of  this  desire  may  induce  a  true  sexual  heat  (like  that 
of  lower  animals),  or  a  mental  state  characterized  by  sensations 
of  anxiety,  in  which  the  individual  yields  to  the  impulse,  and  his 
responsibilty  for  his  action  is  most  questionable.  Should  the  person 
so  affected  not  give  way  to  his  desire,  he  runs  the  danger,  by  this 
enforced  abstinence,  of  injuring  his  nervous  system  by  the  induction 
of  neurasthenia,  or  of  seriously  aggravating  neurasthenia  that  al- 
ready exists. 

"  Excessive  sexual  desire  may  arise  either  from  peripheral  or  from 
central  causes.  The  former  variety  is  less  common.  Such  cases  as 
do  occur,  may  arise  from  pruritus  of  the  genitals,  from  eczema,  or 
from  substances  which  by  their  remote  local  action  stimulate  sexual 
desire,  such  for  instance  as  cantharides. 

"  Sexual  excitement  of  central  origin  is  common  in  those  suffer- 
ing from  congenital  neuropathic  predisposition,  in  hysterical  subjects, 
and  in  states  of  mental  exaltation.  In  such  cases,  when  the  cerebral 
cortex,  including  the  psychosexual  centre,  is  in  a  state  of  hyper- 
aesthesia  (abnormal  excitability  of  the  imagination,  facilitated  asso- 


THE  SEXUAL  EPOCH  OF  THE  MENARCHE.  179 

ciation  of  ideas),  not  only  optical  and  tactile  sensations,  but  also 
auditory  and  olfactory  impressions,  will  arouse  lascivious  per- 
ceptions. 

"  Sexual  hyperaesthesia  may  be  continuous,  with  exacerbations, 
or  intermittent,  and  even  periodic.  In  the  last  case,  according  to 
von  Krafft-Ebing,  it  is  either  an  independent  cerebral  neurosis,  or 
else  a  partial  manifestation  of  a  general  condition  of  mental  excite- 
ment (mania,  dementia  paralytica,  dementia  senilis,  etc.). 

Erotogenic  zones,  the  stimulation  of  which  leads  to  an  increase 
in  the  intensity  of  the  sexual  impulse  and  of  sexual  sensibility,  are 
in  woman  first  of  all  and  principally  the  clitoris,  which  indeed  is 
said  to  be  the  only  zone  of  this  nature  in  the  virgin  state  (an 
opinion  held  by  z:on  Krafft-Ebing  and  others,  but  certainly  most 
improbable)  ;  next  to  this  comes  the  whole  of  the  external  genitals, 
and  especially  the  parts  covered  with  hair ;  also  the  vagina  by  friction 
and  inter  coitum ;  finally  the  nipple  and  its  areola  when  stimulated 
by  titillation  —  an  increase  of  the  excitability  of  this  region  appears 
to  result  from  suckling. 

According  to  Hensen,  the  direct  stimulation  of  the  sexual  impulse 
proceeds  by  way  of  the  dorsal  nerve  of  the  (penis  or)  clitoris;  he 
assumes,  however,  that  certain  states  of  the  reproductive  glands  are 
able  to  induce  an  increase  in  the  irritability  of  the  centres  con- 
nected with  the  aforesaid  nerves.  In  women  it  certainly  appears 
that  particular  states  of  the  ovary  have  a  stimulating  or  inhibiting 
influence  respectively  on  sexual  excitement,  so  that  we  might  ascribe 
to  the  ovaries  the  role  of  a  regulator  of  the  sexual  impulse.  The 
processes  that  occur  in  the  ovary  at  the  time  of  the  ripening  and 
rupture  of  the  graafian  follicle,  and  the  resulting  tension  of  the  folli- 
cular  wall,  induce  by  stimulation  of  the  ovarian  nerves  an  increased 
sensibility  of  the  central  zones,  and  produce  in  a  menstruating  female 
a  condition  of  increased  sexual  excitability,  so  that  slight  stimuli  will 
give  rise  to  a  powerful  orgasm  more  readily  than  would  otherwise 
be  the  case,  when  the  reflex  irritability  of  the  centre  is  less  pro- 
nounced and  the  sexual  impulse  is  consequently  less  intense.  Still 
more  than  during  these  ordinary  menstrual  processes  may  this 
stimulation  be  effective  at  the  time  of  the  menarche,  when  the 
changes  in  the  ovary  occur  for  the  first  time  and  with  the  greatest 
intensity,  so  that  at  this  time  the  individual  may  be  especially  susr 
ceptible  to  sexual  stimulation. 

At  such  times  of  sexual  excitement,  very  slight  external  peripheral 
stimuli,  in  the  form  either  of  tactile  stimulation  of  the  sensory 
nerves  of  the  skin  and  the  external  genital  organs,  or  of  stimula- 
tion of  the  imaginative  and  perceptive  faculties  of  the  brain,  suffice 
to  induce  a  powerful  increase  of  the  sexual  impulse;  whereas  at 


180  THE  SEXUAL  LIFE  OF  WOMAN. 

other  times,  at  which  no  particular  sexual  excitement  exists,  much 
stronger  stimuli  are  needed  to  produce  such  an  effect.  Thus  the 
sexual  impulse  in  women  is  more  readily  and  more  powerfully  in- 
creased in  proportion  as  the  central  organ  is  in  a  condition  of  tem- 
porarily enhanced  excitability  in  consequence  of  the  condition  of 
the  ovaries. 

The  gratification  of  this  impulse,  the  act  of  copulation,  produces 
the  specific  sensation  of  sexual  pleasure;  in  the  female  this  is 
effected  chiefly  by  friction  of  the  glans  clitoridis,  the  organ  when 
erect  projecting  downwards  at  a  right  angle,  and  pressing  upon 
the  intromitted  penis  —  the  friction  of  the  glans  produces  powerful 
mechanical  stimulation  of  the  numerous  plexuses  of  sensory  nerve 
fibres,  which  terminate  in  the  genital  corpuscles  of  Krause.  In 
woman,  then,  we  find  in  the  ovary  the  place  of  origin  and  the  means 
of  regulation  of  the  sexual  impulse,  and  in  the  clitoris  we  find  the 
seat  of  the  specific  sensation  of  sexual  pleasure. 

In  the  poorer  classes  of  society,  an  increase  of  the  sexual  impulse 
occurs  in  women  chiefly  in  consequence  of  bad  example  and  of  un- 
favorable domestic  conditions,  such  as  lead  to  persons  of  opposite 
sexes  sleeping  in  the  same  bed,  and  also  in  consequence  of  the 
abuse  of  alcohol.  In  the  well-to-do  classes,  it  is  the  perusal  of 
modern  equivocal  romances,  visits  to  theatres,  balls,  and  evening 
parties,  and,  speaking  generally,  idleness  combined  with  luxurious 
living,  that  serve  to  stimulate  the  sexual  impulse  in  woman. 

A  certain  dependence  of  the  sexual  impulse  upon  seasonal  varia- 
tions appears  to  exist  also  in  the  human  species.  At  any  rate  in 
certain  months  of  the  year,  a  definite  increase  in  the  number  of 
conceptions  continues  to  recur,  which  indicates  that  during  these 
months  a  larger  number  of  sexually  mature  individuals  is  engaged 
in  the  discharge  of  sexual  functions.  Roscnstadt  regards  this  as  the 
manifestation  of  a  "  physiological  custom,"  immanent  in  the  physical 
constitution  of  civilized  man,  and  inherited  by  him  from  his  animal 
ancestors.  He  explains  it  in  the  following  terms :  "  Primitive  man 
inherited  from  his  mammalian  forefathers  the  peculiarity  of  re- 
producing his  kind  only  during  a  certain  definite  period,  the  period 
of  heat  or  rut.  After  humanity  had  entered  upon  this  period,  copu- 
lation was  effected  en  masse,  as  was  easy  in  view  of  the  primitive 
community  of  sexual  intercourse  before  the  origin  of  marriage.  In 
the  course  of  his  progress  toward  civilization,  however,  man  began 
to  reproduce  his  kind  indifferently  throughout  the  entire  year;  but 
the  original  "  physiological  custom,"  in  accordance  with  which 
reproduction  occurred  at  definite  seasons  only,  did  not  disappear, 
and  persists,  indeed,  to  a  certain  extent  even  to  the  present  day  as  a 
survival  of  earlier  mammalian  life,  and  manifests  itself  in  the  annual 
recurrence  in  certain  months  of  an  increase  in  the  number  of  con- 


THE  SEXUAL  EPOCH  OF  THE  MENARCHE.  181 

ceptions.  The  analogy  in  structure  and  function  between  the  genital 
organs  of  the  human  species  and  those  of  other  mammals  (the 
female  anthropoid  apes  do  not  merely  exhibit  from  time  to  time  a 
period  of  heat,  but  are  subject  to  a  more  or  less  regular  menstru- 
ation), which  for  the  most  part  reproduce  their  kind  only  at  certain 
definite  periods,  leads  to  the  conclusion  that  in  "the  human  species 
also  the  sexual  impulse  may  originally  have  awakened  only  at  a 
particular  season  of  the  year,  and  that  the  persistence  of  this  physio- 
logical custom  in  man,  in  spite  of  the  fact  that  sexual  intercourse 
occurs  all  through  the  year,  and  notwithstanding  that  the  conditions 
necessary  to  awaken  the  sexual  impulse  are  actually  perennial,  must 
be  ascribed  to  inheritance." 

This  view,  which  is  maintained  also  by  other  gynecologists,  finds 
support  in  Kulischer' s  assumption,  based  upon  ethnological  investi- 
gations, according  to  which  coupling  in  primitive  man  took  place 
only  at  certain  seasons,  namely,  at  spring  and  at  harvest-time.  In 
support  of  this  view,  which  was  held  also  by  von  Hell-wold,  Kulischer 
refers  to  a  number  of  actual  and  symbolical  practices  among  different 
races,  which  make  the  assumption  extremely  probable. 

Sexual  desire  in  women,  the  sexual  impulse,  outlasts  the  proper 
sexual  life,  and  manifests  itself  even  after  the  cessation  of  menstrua- 
tion, when  the  possibility  of  conception  has  passed  away ;  it  appears, 
therefore,  to  have  no  necessary  connection  with  the  function  of 
ovulation. 

This  is  indicated  by  the  always  respectable  number  of  women  who 
enter  upon  marriage  even  after  the  climacteric  age.  Thus  the  per- 
centage of  brides  who  were  more  than  45  years  of  age  was :  In 
Prussia,  2.58  per  cent.;  in  England,  1.38  per  cent.;  in  Sweden,  1.53 
per  cent.;  in  Ireland,  0.31  per  cent.  Of  quite  peculiar  interest  are 
the  figures  relating  to  elderly  women  who  marry  men  considerably 
younger  than  themselves.  Thus  we  learn  from  the  tables  of  Routh 
that  in  the  space  of  10  years  in  Ireland  : 

Women  between  the  ages  of  46  and  55  years  married 

Men  below  the  age  of  17  in I  instance. 

Men  between  the  ages  of  17  and  25  in 35  instances. 

Men  between  the  ages  of  26  and  35  in 145  instances. 

Men  between  the  ages  of  36  and  45  in 227  instances. 

And  women  of  ages  greater  than  55  years  married 

Men  below  the  age  of  17  in I  instance. 

Men  between  the  ages  of  17  and  25  in 3  instances. 

Men  between  the  ages  of  26  and  35  in 12  instances. 

Men  between  the  ages  of  36  and  45  in 15  instances. 

Men  between  the  ages  of  46  and  55  in 52  instances. 

In  England  during  the  year  1855  the  age  of  the  bride  exceeded  the 
climacteric  age  in  778  instances.  The  brides  were : 

From  46  to  50  years  of  age  in 135  instances. 

From  51  to  55  years  of  age  in 219  instances. 


182  THE  SEXUAL  LIFE  OF  WOMAN. 

From  56  to  60  years  of  age  in 89  instances. 

From  61  to  65  years  of  age  in • 22  instances. 

From  66  to  70  years  of  age  in 7  instances. 

From  71  to  75  years  of  age  in 3  instances. 

From  76  to  80  years  of  age  in 3  instances. 

In  Bohemia  in  the  year  1872  the  oldest  bride  numbered  no  less 
than  —  86  years. 

Borncr  reports  cases  in  which  the  sexual  impulse  remained  in  full 
activity  after  the  change  of  life,  and  in  some  cases  was  greatly  in- 
creased in  intensity  —  these  latter  individuals  being  in  a  condition 
of  real  torment,  which  induced  them  to  masturbate  to  obtain  relief. 

The  sexual  impulse  may  be  present  in  cases  in  which  the  ovaries 
are  entirely  wanting.  Thus,  Hauff  reports  the  case  of  a  young  girl 
who  had  no  ovaries,  but  was  nevertheless  excessively  addicted  to 
masturbation.  Gl'dveke  speaks  of  a  puella  publica  in  whom  the 
uterus  and  the  ovaries  were  entirely  absent,  but  who  asserted  that 
she  experienced  during  coitus  active  sexual  sensation.  Both 
Kussmaul  and  Pucch  report  similar  experiences  in  cases  of  absence 
or  arrested  development  of  the  uterus. 

As  regards  the  effect  on  the  sexual  impulse  of  the  operation  of 
oophorectomy,  most  authors  state  that  no  change  occurs ;  still,  there 
remain  many  who  express  the  opposite  opinion.  From  the  col- 
lective summary  of  cases  bearing  on  this  question  made  by  Gl'dveke, 
it  appears  that  after  extirpation  of  the  ovaries  the  sexual  impulse 
remains  unchanged  in  the  great  majority  of  cases,  or  at  most  is  but 
slightly  diminished  in  intensity.  He  gar  states  that  he  has  often 
witnessed  a  diminution  of  the  sexual  impulse  after  oophorectomy, 
but  that  this  decline  is  by  no  means  constant,  indeed  he  states  that 
one  of  his  patients  assured  him  that  in  her  case  no  decline  in  the 
intensity  of  the  sexual  impulse  had  followed  the  operation.  Similarly 
variable  reports  were  the  experience  of  Schmalfuss.  In  one  case 
he  found  there  was  but  little  sexual  inclination ;  in  one  case,  dis- 
inclination ;  in  one  case  disinclination  at  first,  followed  by  a  return 
of  inclination.  Briintzel  reports  that  in  four  patients  subjected  to 
oophorectomy,  in  two  cases  the  sexual  impulse  persisted,  but  in  the 
remaining  two  it  was  extinguished.  Kbberle  is  of  opinion  that 
sexual  inclination  diminishes  as  a  result  of  this  operation.  Pcaslcc, 
on  the  contrary,  asserts  that  the  patients  remain  striking  examples 
of  womanhood,  in  whom  all  the  qualities  peculiar  to  their  sex  are 
preserved.  Pcan  observed  as  a  rule  no  difference  in  the  sexual 
impulse  to  result  from  this  operation,  but  he  considers  that  the 
patients  are"  apt  to  describe  in  exaggerated  terms  the  amount  of 
sexual  feeling  that  remains  to  them.  In  one  case,  Spencer  Wells 
observed  after  oophorectomy  an  increase  in  sexual  excitability; 


THE  SEXUAL  EPOCH  OF  THE  "MENARCHE.  183 

Tissier  had  the  same  experience,  and  this  author  believes  that  in 
these  cases  the  sexual  impulse  is  generally  preserved.  On  the  other 
hand,  Bailly  observed  a  case,  in  which  both  ovaries  were  removed 
on  account  of  new  growths,  where  the  sexual  impulse  at  first  be- 
came excessive,  and  then  completely  disappeared.  Anger  and 
Goodell  speak  in  the  same  sense. 

I  am  myself  acquainted  with  a  woman  twenty-six  years  of  age 
who  in  girlhood  underwent  oophorectomy  on  account  of  extremely 
severe  nervous  troubles  associated  with  menstruation ;  she  had  not 
experienced  in  consequence  any  loss  of  the  sexual  impulse;  she 
married  a  man  belonging  to  the  upper  strata  of  society,  and  con- 
sulted me  four  years  later  to  learn  if  she  could  by  any  means  be 
rendered  capable  of  bearing  a  child.  Two  other  cases  have  come 
within  my  personal  experience  in  which  young  women  married  after 
extirpation  of  the  ovaries,  and  in  whom  sexual  desire  and  sexual 
sensation  were  all  that  could  be  wished. 

In  twenty-seven  women  who  had  undergone  the  operation  of 
oophorectomy,  Glavckc  made  inquiries  regarding  the  three  following 
points :  First,  whether  the  sexual  impulse  had  been  affected  by  the 
operation ;  secondly,  whether  during  intercourse  sexual  pleasure  was 
experienced  to  the  same  degree  as  formerly;  and  thirdly,  whether 
during  intercourse  any  kind  of  difference  was  observed  as  compared 
with  pre-operative  experience.  He  obtained  the  following  results : 

Sexual  inclination  was 

Unaffected  in  6  cases 22  per  cent. 

Diminished  in  10  cases 37  per  cent. 

Extinguished  in  n  cases 41  per  cent. 

Sexual  pleasure  during  coitus  was 

Unaffected  in  8  cases 31  per  cent. 

Diminished  in  10  cases ..".... 38  per  cent. 

Extinguished  in  8  cases 31  per  cent. 

In  a  considerable  number  of  cases  the  sexual  impulse  was  thus 
found  by  Glavckc,  not  indeed  to  be  entirely  extinguished,  but  still 
notably  diminished.  In  another  set  of  cases,  the  sexual  impulse 
was  entirely  extinguished,  but  only  in  one  case  was  there  actual 
aversion  to  coitus.  The  women  readily  permitted  intercourse  when 
their  husbands  desired  it,  but  remained  themselves  quite  indifferent. 
The  greater  number  of  these  women  stated  that  the  specific  sensation 
of  pleasure  during  coitus  was  markedly  weakened,  but  not  entirely 
lost ;  in  a  small  proportion,  this  sensation  was  completely  extin- 
guished. In  the  case  of  seven  women  who  complained  that  coitus 
was  very  painful,  Glaveke  found  that  the  calibre  of  the  vagina  was 
much  diminished.  In  these  cases,  the  sensation  of  pleasure  during 
coitus  was  either  greatly  diminished  or  completely  extinguished. 
The  women  permitted  intercourse  very  unwillingly,  their  unwilling- 


184  THE  SEXUAL  LIFE  OF  WOMAN. 

ness  arising,  not  from  any  actual  aversion,  but  because  they  dreaded 
the  pain  which  coitus  produced.  An  extremely  hysterical  woman, 
affected  with  severe  prolapse  of  the  uterus,  stated  that  every  at- 
tempt at  intercourse  was  frustrated  by  violent  hysterical  convulsions. 
The  sexual  impulse  appears  always  to  suffer  first  and  most  severely, 
and  only  after  this  is  the  sensation  of  pleasure  during  coitus  af- 
fected. In  a  few  women  only,  according  to  the  experience  of  this 
author,  was  the  sexual  impulse  quite  unaffected  by  the  removal  of 
the  ovaries. 

Amputation  of  the  clitoris  appears  notably  to  diminish  both  the 
sexual  impulse  and  the  sensation  of  sexual  pleasure,  but  the  results 
of  clitoridectomy  for  the  cure  of  masturbation  are  by  no  means  al- 
ways favorable.  In  the  women  of  the  Russian  sect  of  the  Skopstki, 
the  clitoris,  the  nymphte,  and  a  part  of  the  labia  majora  are  removed, 
in  order  to  destroy  sexual  desire.  According  to  row  Krafft-Ebing  it 
is  probable  that  in  the  virgin  the  clitoris  is  the  only  erotogenic  zone, 
that  is  to  say,  that  only  by  the  stimulation  of  the  clitoris  can  erec- 
tion, the  orgasm,  and  the  sensation  of  ejaculation  be  induced.  It 
is  probable  that  the  vagina  becomes  erotogenic  only  as  a  result  of 
coitus;  thenceforward,  however,  the  erotogenic  significance  of  the 
clitoris  is  notably  lessened,  and  in  multiparae  may  entirely  disappear. 

NYMPHOMANIA,  ANESTHESIA  AND  PSYCHOPATHIA  SEXUALIS. 

The  sexual  impulse  in  women  is  subject  to  morbid  changes,  both 
in  the  way  of  increase  and  of  diminution,  exhibiting  abnormal  vio- 
lent increase  (nymphomania),  or  declining  to  the  state  of  com- 
plete frigidity  and  sexual  indifference,  or,  finally,  manifesting  itself 
in  some  perverse  manner  ( psychopathia  sexualis). 

Psychopathically  increased  sexual  impulse  in  woman  is  known 
as  nymphomania  or  uteromania.  In  such  women  there  is  a  dominant 
state  of  psychical  hypersethesia,  principally  in  the  genital  sphere. 
The  most  indifferent  perceptions  give  rise  to  erotic  sensations  and 
to  lascivious  impulses.  All  sensory  perceptions  obtain  a  sexual  con- 
tent, and  induce  stimulation  of  the  cerebral  cortex..  All  sensation  and 
all  activity  in  such  unhappy  beings  ultimately  concentrates  itself  in 
the  act  of  copulation,  or  in  some  other  form  "of  sexual  gratifica- 
tion, the  greatest  perversities  of  sexual  practice  frequently  arising, 
masturbation,  tribadism,  and,  for  the  most  part,  prostitution,  even 
in  the  case  of  married  women. 

The  nymphomaniacal  woman,  says  von  Krafft-Ebing,  endeavors 
to  allure  men  by  means  of  exposure  of  the  genital  organs  or  indecent 
gestures;  the  sight  of  man  produces  intense  sexual  excitement,  which 
is  gratified  by  masturbation  or  by  stimulatory  movements  of  the 
pelvis.  According  to  this  author,  nymphomania  is  not  very  infre- 


THE  SEXUAL  EPOCH  OF  THE  MENARCHE.  185 

quent  at  the  climacteric  period ;  it  may  even  occur  in  old  age.  Ab- 
stinence in  association  with  simultaneous  excitement  of  the  sexual 
sphere  by  mental  or  by  peripheral  stimuli  (pruritus  pudendi,  oxyuris, 
etc.),  may  induce  these  states,  probably,  however,  only  in  those 
hereditarily  predisposed. 

The  history  of  antiquity  contains  records  of  the  corrupt  practices 
of  nymphomaniacal  empresses.  Thus,  Messalina  furnishes  a  well- 
known  historical  example  of  the  abnormal  violence  of  a  pathologi- 
cally intensified  sexual  impulse  in  woman.  She  w.as  given  the  agno- 
men of  invicta,  having  received  the  embraces  of  fourteen  athletes. 
Pliny  says  of  her,  die  ac  node  superavit  quinto  et  vicessimo  con- 
cubitu;  and  Juvenal  writes  of  her  the  verses, 

tamen  ultima  cellam 

Clausit,  adhuc  ardens  rigidse  tintigine  vulvae 
Et  resupina  jacens  multorum  absorbuit  ictus 
Et  lassata  viris,  necdum  satiata,  recessit. 

In  corrupt  Rome,  Messalina  was  not  the  only  woman  necdum 
satiata,  ever  insatiable ;  we  need  only  refer  to  the  orgies  of  an  Ag- 
gripina,  a  Livia,  a  Mallonia,  or  a  Poppaea ;  and  Seneca  hurls  against 
the  women  of  his  day  the  reproach,  adeo  pcrversum  comments  genus 
impudicitia  viros  ineunt.  And  of  Cleopatra,  the  beautiful  Egyptian 
queen,  Marcus  Antonius  writes  in  a  letter  to  his  physician,  Soranus, 
that  she  had  such  violent  sexual  desire  as  to  lead  to  her  having 
connection  in  a  brothel  with  106  men. 

Through  the  report  of  Herodotus  it  is  well  known  that  the  pyramid 
of  Cheops  was  built  by  the  numerous  lovers  of  the  daughter  of 
this  king,  who  raised  this  enormous  monument  in  recognition  of 
the  innumerable  times  she  had  yielded  herself  to  their  desires.  On 
record  also  are  the  sexual  excesses  of  the  Roman  ladies  at  the  festival 
of  Saturn,  the  festival  of  the  Bona  Dea,  and  the  festival  of  Priapus ; 
indeed,  many  of  these  women  allowed  themselves  to  be  debauched 
in  the  temples  (Ploss  and  Bartels). 

But  returning  to  the  present  day,  both  gynecologists  and  alienists 
record  numerous  cases  of  great  pathological  increase  in  the  in- 
tensity of  the  sexual  impulse  in  women.  According  to  Lombroso, 
such  continued  ardency  of  sexual  desire  occurs  chiefly  in  women 
with  an  inherited  tendency  to  crime  and  to  prostitution,  whose 
natures  exhibit  a  commingling  of  lasciviousness  with  barbarism. 
He  gives  examples  of  such  women,  one  of  whom  surrendered  her- 
self to  her  husband's  laborers ;  another  had  as  her  lovers  all  the 
desperadoes  of  Texas ;  a  third  had  intercourse  with  all  the  herdsmen 
of  her  village ;  a  fourth,  though  her  husband  occupied  a  good 
social  position,  led  the  life  of  a  prostitute;  a  fifth,  a  cultured  and 


i86  THE  SEXUAL  LIFE  OF  WOMAN. 

intelligent  woman,  entertained  a  common  bricklayer,  and  wrote 
to  him  letters  full  of  shameless  declarations  of  her  sexual  passion ; 
further  he  writes  of  a  series  of  criminals,  in  whom,  indeed,  increased 
sexual  desire  is  a  common  phenomenon ;  one  of  these,  a  thief,  ex- 
perienced sexual  excitement  at  a  mere  glance  at  a  good-looking  man ; 
a  murderess,  in  whom  lascivious  feeling  induced  'masturbation  when- 
ever she  saw  a  man,  and  who  made  experiments  in  sexual  inter- 
course with  dogs;  another,  who  often  took  to  bed  with  her,  in  ad- 
dition to  her  son,  three  or  four  men  selected  at  random  from  the 
streets;  and  many  others.  Jolly  reports  the  case  of  a  widow,  a 
celebrated  I  ion  ne  of  the  demi-monde,  who  kept  in  her  desk,  side  by 
side  with  devotional  literature,  a  number  of  lascivious  books  and 
preparations  of  cantharides,  and  entertained  quite  a  number  of 
powerfully-built  lovers  drawn  from  the  lowest  canaille. 

In  hysterical  women  the  sexual  impulse  is  frequently  excessive, 
and  may  increase  to  such  a  degree  as  to  produce  hallucinations  of 
coitus ;  sometimes,  on  the  other  hand,  the  impulse  is  extinguished, 
or  psychopathically  metamorphosed,  passing  in  a  most  paradoxical 
manner  from  sexual  frigidity  to  lascivious  reflections  and  continuous 
occupation  with  sexual  affairs ;  not  uncommon  in  such  women  are 
false  accusations  of  indecent  assaults  of  which  they  assert  them- 
selves the  victims. 

Lombroso  gives  several  examples  of  the  increase  of  the  sexual 
impulse  in  hysterical  women :  "A  hysterical  girl  visited  a  physician, 
and  said  to  him :  '  I  am  still  a  virgin,  take  me ;'  she  submitted  him 
to  the  utmost  extremity  of  provocation,  and  asserted  afterward  that 
she  had  been  violated.'  Another  hysterical  subject,  a  rich  young 
lady,  met  a  workman  in  the  street,  offered  herself  to  him,  was  ac- 
cepted, and  when  she  returned  home  related  the  affair  with  laughter. 
A  third  sought  men  from  the  street  in  order  to  find  one  suffering 
from  syphilis,  her  object  being  to  infect  her  own  husband  with  the 
disease." 

According  to  the  observations  of  Schnle,  young  married,  hysteri- 
cal women  not  infrequently  run  away  with  a  waiter  during  the 
honeymoon  journey.  This  author  also  points  out  that  in  women 
moral  insanity  is  especially  apt  to  manifest  itself  during  the  first 
years  of  married  life.  Many  advocate  a  far-reaching  libertinism, 
and  threaten  to  enter  a  brothel.  In  these  forms  we  observe,  in 
addition  to  ill-temper  and  malignity,  especially  obscenity  and 
tribadism. 

Such  a  case,  observed  by  Giraud  and  quoted  by  rou  Krafft-Ebing, 
is  the  following:  Marianne  L.,  of  Bordeaux,  during  the  night, 
while  her  master  was  sleeping  soundly  under  the  influence  of  nar- 
cotics she  had  administered,  was  in  the  habit  of  giving  up  her 


THE  SEXUAL  EPOCH  OF  THE  MENARCHE.  187 

master's  children  to  her  lover  for  his  sexual  gratification,  and  made 
them  witnesses  of  the  most  immoral  scenes.  It  appeared  that  L. 
was  hysterical,  suffering  from  hemianaesthesia  and  convulsive 
seizures,  and  that  before  her  illness  she  had  been  a  sensible  and 
trustworthy  individual.  After  the  illness,  however,  she  prostituted 
herself  in  the  most  shameless  manner  and  completely  lost  her  moral 
sense. 

Galen  relates  of  his  own  mother  that  she  suffered  from  nympho- 
mania,  and  that  in  the  attacks  she  bit  her  female  slaves  like  a  wild 
animal. 

As  a  negative  aspect  of  the  sexual  impulse  in  woman  we  must 
regard  the  absence  of  the  impulse,  or  anaesthesia  sexualis,  and  also 
the  deficiency  of  the  sensation  of  pleasure  during  the  act  of  copula- 
tion, or  clysparetmia. 

Of  dyspareunia  we  shall  speak  more  at  length  later,  in  connec- 
tion with  the  pathology  of  copulation.  As  regards  the  entire  lack  of 
the  sexual  impulse,  however,  in  women  whose  genital  organs  are 
normally  developed  and  normal  in  the  performance  of  their  functions, 
and  whose  cerebral  condition  is  also  normal,  we  must  consider  such 
lack  an  extremely  rare  condition,  if  indeed  it  ever  occurs.  It  is 
only  in  cases  in  which  the  female  genital  organs  are  wanting, 
wholly  or  to  a  considerable  extent,  or  in  which  there  are  important 
cerebral  disturbances  or  states  of  mental  degeneration,  .that  the 
sexual  impulse  is  wanting. 

Normally,  in  the  young,  sexually  unspoiled  girl,  the  sexual  in- 
stinct34 slumbers  in  the  cerebral  cortex,  but  becomes  active,  as  sen- 
sation, perception,  and  impulse,  as  soon  as  the  cerebral  centre  has 
been  aroused  by  mental  impressions  or  by  physical  peripheral  stimu- 
lation of  the  genital  organs  and  their  environment.  Among  stimuli 
of  the  latter  class  must  be  reckoned  the  menstrual  stimulus,  set 
on  foot  by  the  developmental  processes  of  puberty.  These  stimuli 
arouse  in  the  cerebral  cortex  sensations  and  perceptions  which,  ris- 
ing to  specific  sexual  feelings,  produce  an  impulse  to  increase  the  in- 
tensity of  these  feelings  by  purposive  action ;  thus  is  awakened  the 
sexual  impulse,  the  strength  of  which  is  extremely  variable. 

Only  when  the  cerebral  cortex,  as  the  place  of  origin  of  sensa- 

34  It  seems  expedient  to  point  out  that  whilst  in  this  work  the  German  word 
Gcschlechtstrieb  has  in  the  great  majority  of  cases  been  rendered  in  English 
by  the  term  sc.vual  impulse,  on  two  or  three  occasions,  as  here,  the  author 
speaks  of  the  Gcschlcchtstrieb  as  composed  of  sensation,  perception,  and  im- 
pulse (Drang),  when  for  obvious  reasons  the  rendering  sexual  instinct  be- 
comes necessary.  Though  the  term  sexual  impulse  is,  T  think,  in  more  gen- 
eral use  than  the  term  sexual  instinct,  it  must  not  be  forgotten  that  the 
inclination  towards  sexual  congress  is  composite  in  nature,  and  that  an 
impulse  in  the  strict,  sense  of  the  term  is  only  one  element  in  its  com- 
position.—  TR. 


i88  THE  SEXUAL  LIFE  OF  WOMAN. 

tions  and  perceptions,  fails  to  perform  its  functions  in  the  manner 
just  described,  or  when  the  anatomico-physiological  processes  in 
the  genital  organs  which  normally  act  as  peripheral  stimuli  fail  to 
occur,  or  when  there  is  a  failure  in  the  conducting  tracts,  are  sexual 
perceptions  and  impulses  lacking.  Such  anomalies  may  be  con- 
genital. A  milder  form  is  that,  likewise  congenital,  in  which  a 
woman  has  a  sexually  "  cold  nature ;"  in  these  cases  the  sexual  im- 
pulse is  not  completely  wanting,  but  it  is  so  slight  in  intensity  that 
it  can  be  awakened  only  by  very  powerful  stimuli,  and  in  her  normal 
state  the  woman  so  affected  is  quite  free  from  any  wish  for  sexual 
gratification. 

Such  congenital  subnormal  intensity  or  rntire  lack  of  the  sexual 
impulse  may  be  due  to  very  various  causes.  According  to  von 
Krafft-Ebing,  these  causes  may  be  organic  or  functional,  mental  or 
physical,  and  central  or  peripheral.  The  declining  intensity  of  the 
sexual  impulse  with  the  advance  of  years,  and  the  temporary  dis- 
appearance of  that  impulse  after  the  sexual  act,  are  both  physiological 
occurrences.  Education  and  mode  of  life  have  a  marked  influence 
on  the  intensity  of  the  vita  sexualis.  Strenuous  mental  activity, 
earnest  study,  severe  physical  exertion,  mental  depression,  and  sexual 
continence,  notably  diminish  the  excitability  of  the  sexual  impulse. 
At  first,  indeed,  abstinence  leads  to  an  increase  in  the  intensity  of 
the  impulse,  but  sooner  or  later  the  functional  activity  of  the  organs 
of  generation  declines,  and  therewith  also  the  intensity  of  the  sexual 
impulse.  As  peripheral  causes  of  diminution  or  disappearance  of  the 
sexual  impulse,  von  Krafft-Ebing  mentions  oophorectomy,  degenera- 
tion of  the  reproductive  glands,  marasmus,  sexual  excess,  whether  in 
the  form  of  coitus  or  of  masturbation,  and  alcoholism.  In  like  man- 
ner is  to  be  interpreted  the  disappearance  of  the  sexual  impulse  in 
general  disorders  of  nutrition  (diabetes,  morphinism,  etc.). 

A  decline  in  the  intensity  of  the  sexual  impulse  in  consequence  of 
degeneration  of  the  conducting  tracts,  is  found,  according  to  von 
Krafft-Ebing,  in  diseases  of  the  brain  and  the  spinal  cord.  Central 
affection  of  the  sexual  impulse  may  be  due  to  organic  disease  of  the 
cerebral  cortex  (dementia  paralytica,  general  paralysis  of  the  insane, 
in  the  later  stages),  or  it  may  be  due  to  functional  disorder,  such 
as  hysteria,  or  to  mental  diseases  (melancholia  or  hypochondriasis). 

Finally,  in  some  instances,  the  sexual  impulse  in  women  manifests 
itself,  not  in  the  normal  manner  with  copulation  with  the  male  as  its 
goal,  but  in  a  form  demanding  some  abnormal  kind  of  gratification 
(psychopathia  sexualis),  whether  it  be  because  sexual  intercourse 
with  the  male  affords  the  woman  no  enjoyment,  or  simply  because 
no  opportunity  exists  for  such  intercourse. 

Masturbation  is  very  frequent;  the  habit  having  been  acquired 


THE  SEXUAL  EPOCH  OF  THE  MENARCHE.  189 

from  bad  example  by  the  girl  during  the  menarche,  it  is  sometimes 
continued  by  the  wife  during  married  life.  In  these  cases  we  often 
find  distinct  changes  in  the  genital  organs,  such  as  hypertrophy  of 
the  clitoris,  enlargement  and  bluish  discoloration  of  the  nymphae, 
retroversion  of  the  uterus,  tenderness  and  displacement  of  the  ovaries, 
considerable  vaginal  discharge,  and  sometimes  menorrhagia. 

Kussmaul  draws  attention  to  the  connection  between  masturbation 
and  nymphomania,  on  the  one  hand,  and  imperfect  development  of 
the  uterus  and  the  other  genital  organs,  on  the  other.  Campbell 
records  the  case  of  a  woman  addicted  to  masturbation,  who  had 
never  menstruated,  and  who,  in  addition  to  imperfectly  developed 
genital  organs,  had  a  dermoid  cyst  of  the  ovary.  In  a  young  woman 
who  indulged  in  masturbation,  Aran  found  that  the  uterus  and  its 
annexa  were  imperfectly  developed.  Vaddington  also  describes  a 
case  of  abnormal  sexual  impulse  which  was  associated  with  absence 
of  the  uterus. 

Troggler  reports  the  case  of  a  woman  twenty  years  of  age,  who 
had  been  six  months  married  to  a  healthy,  potent  man,  was  herself 
healthy  and  blooming,  with  a  good  family  history,  and  had  never 
suffered  from  any  severe  illness.  At  the  age  of  thirteen  she  had 
learned  to  masturbate,  effecting  this  by  stimulation  of  the  clitoris. 
Now  she  found  no  gratification  in  coitus,  so  that  she  continued  to 
masturbate,  and  during  coitus  obtained  satisfaction  by  manual  fric- 
tion of  the  clitoris.  Examination  showed  that  the  clitoris  was  strik- 
ingly large,  the  vagina  flaccid,  and  that  there  was  some  vaginal  dis- 
charge ;  in  other  respects  the  genital  organs  were  normal. 

Not  infrequent,  it  may  be  in  those  whose  mental  condition  is  in 
other  respects  fairly  normal  or  it  may  be  in  psychopathic  subjects, 
is  the  existence  of  contrary  sexual  sensation,  or  sexual  inversion,  a 
condition  which  has  been  described  by  Casper,  Westphal,  von 
Krafft-Ebing,  and  Moll,  and  has  indeed  been  well  known  since  the 
days  of  antiquity.  In  the  case  of  a  considerable  number  of  notable 
women,  homosexual  practices  have  been  recorded.  According  to 
the  observations  of  Coffignon,  in  Paris  the  homosexual  instinct, 
when  occurring  in  other  women  than  prostitutes,  is  found  chiefly 
among  the  ladies  of  the.  aristocracy. 

Of  homosexually  inclined  women,  some  engage  in  the  practice  of 
tribadism,  familiar  to  the  ancient  world,  and  recorded  by  Martial  in 
a  satire,  in  which  sexual  gratification  is  obtained  by  mutual  friction 
of  the  genital  organs,  or  by  penetration  of  one  woman's  clitoris  into 
the  vagina  of  the  other ;  whilst  some  indulge  in  the  amor  lesbicus, 
in  which  gratification  is  obtained  lambendo  lingua  gcnitalia,  a  very 
ancient  practice  indeed,  transported  from  Phoenicia  to  Greece  (where 
in  especial  it  was  indulged  in  by  the  women  of  Lesbos),  and  later 


190  THE  SEXUAL  LIFE  OF  WOMAN. 

from  Syria  to  Italy,  where  it  was  widely  diffused  among  the  Romans 
of  the  imperial  age.  Sappho,  celebrated  as  the  tenth  muse,  is  sup- 
posed to  have  been  addicted  to  the  practice  of  Lesbian  love. 

All  such  homosexual  (female)  individuals  are,  then,  endowed  with 
the  perverse  instinct  toward  sexual  connection  with  women  instead  of 
with  men.  In  such  cases,  the  genitals  are  usually  quite  normal ; 
sometimes,  however,  the  woman  thus  affected  is  markedly  of  a  male 
type,  being  called  by  von  Krafft-Ebing  a  gynandrist,  the  affection 
itself  being  termed  gynandry;  when  the  woman  concerned  not  only 
possesses  a  homosexual  impulse,  but  also  in  other  respects  exhibits 
tendencies  properly  characteristic  of  the  male  sex,  she  is  called  virago, 
and  the  affection  is  termed  viraginity. 

I  had  under  my  care  such  a  woman,  belonging  to  the  upper  cir- 
cles of  society,  who  had  been  married  sixteen  years  before,  had 
lived  a  married  life  for  six  years  (during  which  she  remained  bar- 
ren), and  had  then  separated  from  her  husband.  She  was  of  a 
very  masculine  disposition,  smoked,  gamed,  drank  like  a  student, 
and  preferred  to  wear  men's  clothing,  and  she  bestowed  her  affec- 
tions on  a  female  companion.  Examination  of  the  genital  organs 
disclosed  no  abnormality  beyond  a  slight  vaginal  catarrh.  Menstru- 
ation was  regular,  and  the  general  appearance  showed  no  departure, 
with  the  exception  of  a  slight  moustache  that  shaded  the  upper  lip, 
from  that  of  a  normal  feminine  beauty. 

Mantegazza  is  of  opinion  that  in  the  case  of  many  unhappy  mar- 
riages, in  which  the  source  of  the  unhappiness  is  obscure,  the  trouble 
is  to  be  found  in  the  homosexual  inclination  of  the  wife.  Martincau 
and  Moll  report  that  married  women  who  are  homosexually  inclined, 
indulge  in  sexual  intercourse  with  other  women  behind  their 
husbands'  back.  Duhoussct,  at  a  meeting  of  the  Anthropological 
Society  at  Paris  in  1877,  related  the  almost  incredible  case  of  a 
married  homosexual  woman  who,  in  intercourse  with  another 
woman,  transferred  to  the  latter  her  husband's  semen,  so  as  to 
induce  pregnancy. 

Many  writers  on  forensic  medicine,  Tardieu,  Pfaff,  Schauenstein, 
Wald,  and  Mantegazza,  for  instance,  have  recorded  that  in  numer- 
ous circles  of  European  society  women  practice  masturbation  and 
tribadism  (sodomy,  so  called)  with  dogs  and  monkeys;  and  Plu- 
tarch's statement  is  well  known  regarding  Egyptian  women  and  the 
sacred  goat,  Mendes,  that  the  women  who  were  locked  in  with  this 
animal  practiced  sodomy  therewith ;  and  again  it  is  asserted  that 
the  serpents  in  the  temple  of  ^sculapius  and  also  in  private  houses 
were  employed  in  the  practice  of  sodomy. 

Von  Maschka  records  a  case  which  came  before  the  courts  a  few 
years  ago  in  Prague,  in  which  a  woman  forty-four  years  old  con- 


THE  SEXUAL  EPOCH  OF  THE  MENARCHE.  191 

fessed  that  "  in  consequence  of  the  very  ardent  temperament  she 
possessed,  she  had,  perhaps,  as  often  as  six  times  indulged  herself 
with  her  house  dog,  which  jumped  between  her  legs  and  licked  her ; 
that  she  took  the  animal  between  her  bare  legs,  stroked  its  belly 
until  its  penis  became  erect;  then,  supporting  herself  on  the  back 
of  a  chair,  she  pressed  the  animal  against  herself,  introduced  its 
penis  between  her  labia  majora,  and  let  it  continue  its  movements 
until  its  semen  had  been  ejaculated."  Examination  of  the  genital 
organs  of  this  woman  disclosed  no  abnormality. 

Schauenstein  reports  the  case  of  a  girl  who  carried  out  unchaste 
practices  with  a  little  dog  to  an  utterly  immoderate  extent,  so  that 
after  the  lapse  of  some  years  she  died  in  an  asylum.  In  a  case  re- 
corded by  Wold,  a  maid  servant  was  observed  in  lewd  practices  with 
a  poodle ;  she  supported  herself  on  elbows  and  knees,  while  the  dog 
copulated  with  her  from  behind. 

A  woman  about  thirty  years  of  age,  who  had  lived  with  her  hus- 
band in  sterile  marriage  for  nine  years,  complained  to  me  that  she 
had  not  for  a  long  time  had  sexual  intercourse,  since  during  copula- 
tion she  not  only  experienced  no  sexual  pleasure,  but  actually  felt 
a  loathing  to  the  act;  on  the  other  hand,  she  was  subject  to  an  un- 
controllable impulse  to  handle  the  genital  organs  of  children,  both 
of  the  male  and  of  the  female  sex,  and  this  performance  gave  her 
sexual  gratification ;  during  the  menstrual  period,  this  impulse  over- 
powered her  will.  Local  examination  in  this  patient  showed  that  the 
uterus  was  enlarged  and  retroflexed,  and  that  there  was  anaesthesia 
of  the  vagina. 

An] el  reports  the  following  case  of  periodic  psychopathia  sexualis, 
associated  with  menstruation.  A  lady  of  quiet  disposition,  near  the 
climacteric.  Serious  congenital  predisposition.  During  youth  suf- 
fered from  attacks  of  minor  epilepsy.  Married,  but  childless.  Sev- 
eral years  ago,  after  violent  emotional  disturbance,  she  had  a 
hystero-epileptic  seizure,  followed  by  post-epileptic  mania  lasting 
several  weeks.  Thereafter,  insomnia  for  several  months.  As  a 
sequel,  continually  recurrent  menstrual  insomnia,  accompanied  by  an 
impulse  to  embrace  boys  under  ten  years  of  age,  to  kiss  them,  and  to 
handle  their  genital  organs.  Impulse  toward  coitus,  to  close  sexual 
contact  with  a  grown  man,  non-existent  at  this  time.  The  patient 
often  speaks  openly  of  her  morbid  impulse,  and  begs  that  she  may 
be  supervised,  as  she  feels  unable  to  answer  for  her  own  conduct. 
In  the  intervals,  however,  she  carefully  avoids  all  reference  to  the 
matter,  is  strictly  decent  in  her  conduct,  and  in  no  way  sexually 
ardent. 

Tribadism  is  frequently  mentioned  by  the  writers  of  classical 
antiquity,  especially  by  those  of  Greece,  where  the  cult  of  naked 


192  THE  SEXUAL  LIFE  OF  WOMAN. 

beauty  encouraged  sexual  excitement  of  this  character.  This  form 
of  unchastity  was  common  among  the  flute-playing  girls  of  Greece, 
and  at  the  secret  festivals  of  such  associates  Aphrodite  Peribasia  was 
invoked.  Litcian,  in  his  dialogues  of  hetairai,  depicts  the  intensely 
passionate  nature  of  these  homosexual  unions  between  girls.  Lom- 
broso  reproduces  Juvenal's  description  of  such  a  love-feast.  "  When 
the  flute  calls  to  the  dance,  the  maenads,  inflamed  with  wine  and 
beer,  loosen  their  long  tresses,  they  sigh  languishingly  and  eagerly, 
and  an  ardent  desire  draws  them  one  to  another,  the  desire  and  the 
passion  of  the  dance  gives  their  voices  an  alluring  sound ;  nothing 
now  can  serve  to  bridle  their  unrestrained  desires.  Lacasclla  swings 
her  wreath,  which  she  has  won  in  the  contest  of  lascivious  gestures 
and  movements,  but  even  she  must  give  way  before  Medullina  with 
her  ardent  postures.  About  these  games  there  is  no  trace  of  un- 
reality, and  the  most  rigid  Spartan,  hardened  from  the  very  cradle, 
even  old  Nestor  himself,  notwithstanding  his  hernia,  could  not  fail 
to  be  stimulated  by  such  an  inflammatory  spectacle." 

In  the  present  day,  also,  the  practice  of  tribadism  is  more  widely 
diffused  than  people  in  general  imagine.  I  have  often  encountered 
instances  of  it  in  ladies  of  good  position,  who  were  past  their  first 
youth,  who  would  not  or  could  not  marry,  and  who  undertook 
extensive  and  long-enduring  journeys  with  a  female  "  companion," 
of  similar  age,  or  perhaps  a  little  younger.  Their  erotic  needs,  which 
could  not  be  gratified  in  normal  fashion,  led  to  this  sexual  per- 
version—  a  tendency  observable  especially  in  persons  with  neuro- 
pathic predisposition,  or  with  a  liability  to  hysteria  or  to  epilepsy. 
Sometimes  such  girls,  even  before  puberty,  show  an  inclination  to 
wear  boys'  clothes,  to  avoid  all  feminine  manual  occupations,  and 
to  examine  and  to  handle  the  genital  organs  of  their  playmates. 
Even  after  puberty,  such  tribadists  like  to  make  a  parade  of  mascu- 
line attitudes,  they  have  their  hair  cut  short,  wear  clothes  of  a 
masculine  cut,  smoke  a  great  deal,  and  show  in  their  conversation, 
and  still  more  in  their  letters,  great  exaltation  of  the  passions.  It 
not  infrequently  happens  that  an  elderly  lady  who  has  lived  well  in 
her  day,  and  from  youth  upward  has  had  much  intercourse  with 
men,  comes  at  last  to  lament  her  worthlessness  to  men,  and  from 
this  proceeds  to  the  idea  of  obtaining  sexual  enjoyment  by  means 
of  tribadism.  The  tribadistic  union  sometimes  lasts  for  several 
years,  but  in  most  cases  the  alliances  are  quickly  and  frequently 
changed. 

According  to  Ta.rit,  tribadism  is  fairly  common  among  the  mar- 
ried women  of  Paris,  and  in  upper-class  women  is  extremely  preva- 
lent. This  author  describes  with  what  industry  and  perseverance 
many  elderly  tribadists  endeavor  to  win  for  themselves  and  to  seduce 


THE  SEXUAL  EPOCH  OF  THE  MENARCHE.  193 

young  girls,  just  as  old  women  often  work  hard  to  gain  money 
for  the  enjoyment  of  the  favored  person. 

In  these  unions,  according  to  the  descriptions  of  Lombroso,  very 
remarkable  phenomena  occur.  A  particular  jargon  arises  with  ten- 
der designations  for  this  or  that  bodily  beauty;  a  violent  jealousy 
develops,  and  a  newly  united  pair  keep  together  as  much  as  possible 
for  fear  of  losing  one  another's  affection ;  the  "  friends "  tread 
always  in  one  another's  footsteps.  This  author  rightly  points  out 
that  the  very  numerous  romances  describing  relations  of  this  kind 
prove  the  diffusion  of  this  vice  in  "  high  life."  Novels  of  this  class 
are  referred  to  by  Mantegazza,  in  his  book,  "  Woman  as  Criminal  and 
Prostitute."  He  mentions  :  Diderot,  "  La  Religieuse ;"  Bdzac,  "  La 
Fille  aux  Yeux  d'Or ;"  Gautier,  "  Mademoiselle  de  Maupin ;" 
Feydeau,  "  Le  Comtesse  de  Cholis ;"  Flaubert,  "Salammbo;"  Belot, 
"  Mademoiselle  Giraud  ma  Femme ;"  Willbraud,  "  Fridolins  Heim- 
liche  Ehe ;"  Graf  Stadion,  "  Brick  and  Brack ;"  Sacher-Masoch, 
"  Venus  im  Pelz."  Zola,  also,  in  "  Nana  "  and  "  La  Curee,"  and 
Butti  in  "  L'Antona,"  make  some  reference  to  this  matter. 

Sauval  relates  of  the  dissolute  life  at  the  court  of  the  French 
king,  Francis  I,  that  the  women  learned  also  to  play  the  part  of 
men ;  a  princess  had  a  hermaphrodite  maid-of-honor,  and  the  court 
and  all  Paris  gossiped  about  the  Lesbian-loving  ladies,  whose  hus- 
bands were  delighted,  since  they  were  thus  quite  freed  from  jealousy, 
and  prized  their  wives  above  all  on  this  account.  Such  a  mode  of 
life  was  so  pleasing  to  many  ladies  that  they  refused  to  marry,  and 
refused  also  to  allow  their  "  friends  "  to  marry. 

Tribadism  is  very  common  among  prostitutes.  According  to 
Parent-Duchatelet,  tribadism  begins  only  after  prostitution  has  long 
been  practised,  between  the  twenty-fifth  and  the  thirtieth  year  of 
life;  generally  there  is  a  notable  difference  in  age  and  also  in  beauty 
between  the  two  women  forming  a  tribadistic  alliance,  and  as  a  rule 
the  younger  and  prettier  of  the  pair  is  the  more  passionately  sensi- 
tive and  the  more  constant.  Parent-Duchatelet  endeavours  to  ex- 
plain the  origin  of  tribadism  by  referring  to  the  manner  in  which  in 
brothels  and  reformatories  the  women  are  closely  packed  together, 
to  the  enforced  abstinence  from  normal  sexual  intercourse  (in 
prisons  and  reformatories),  to  the  loathing  for  men  sometimes  felt 
by  prostitutes,  and  to  the  opportunities  for  mutual  observation  of 
the  most  intimate  nudities.  Even  women  who  at  first  object  to  it 
most  vehemently,  commonly  give  way  to  this  vice  after  eighteen  or 
twenty  months. 

Among  103  prostitutes  examined  by  Lombroso,  he  found  tribadism 
to  be  practiced  by  five.  He  considers  the  principal  cause  of  tribadism 
to  be  in  the  lascivious  search  for  new  and  unnatural  pleasures,  and 

13 


194  THE  SEXUAL  LIFE  OF  WOMAN. 

quotes  in  illustration  the  characteristic  remark  of  Catharine  II,  her- 
self a  tribadist,  "  Why  did  not  nature  endow  us  with  a  sixth  sense?  " 
Female  criminals  who  seduce  others  to  the  practice  of  tribadism 
have  usually  themselves  acquired  the  vice  during  a  long  term  of 
imprisonment  —  it  is,  in  fact,  the  long-sentence  criminals,  women 
with  a  congenital  inclination  toward  crime,  that  incline  also  to  un- 
natural vice.  The  influence  of  environment  is,  according  to  Lorn- 
broso,  indicated  by  the  fact  that  the  most  confirmed  criminals,  in 
prisons  for  women,  corrupt  in  this  manner  so  many  of  the  inmates 
who  are  merely  "  criminaloids,"  and  corrupt  even  the  wardresses. 
Further,  he  is  led  to  conclude,  the  confinement  in  close  association 
of  so  many  extremely  sensual  and  prostituted  women,  leads  to  the 
origin  of  a  kind  of  ferment  of  new  lascivious  desires,  and  causes  an 
increase  of  one  form  of  degeneracy  by  means  of  another.  Prosti- 
tutes often  see  one  another  naked,  sleep  two  or  three  together  in 
the  same  bed ;  similar  things  occur  in  boarding-schools.  In  asylums 
also  we  may  observe  that  the  admission  of  a  tribadist  will  result  in 
the  infection  of  all  the  inmates  with  this  vice. 

According  to  Moll's  estimate,  25  per  cent,  of  the  prostitutes  of 
Berlin  practice  tribadism.  According  to  the  experience  of  this 
author,  in  cases  in  which  tribadists  live  in  concubinage,  one  of  them 
is  always  a  prostitute;  the  active  and  the  passive  role  are  always 
played  by  the  same  respective  members  of  the  alliance;  the  active 
member  is  called  "  papa  "  or  "  uncle,"  is  usually  a  prostitute,  and, 
like  the  man  in  the  married  state,  possesses  great  comparative  free- 
dom in  sexual  matters,  whilst  the  passive  member,  the  "  mother," 
is  not  allowed  to  form  any  sexual  relations  outside  the  concubinage. 

According  to  Riccardi,  many  frigid  prostitutes  practice  with  pleas- 
ure clitoris-masturbation,  cunnilictio,  and,  especially,  sapphism,  pre- 
ferring these  perversions  to  the  normal  sexual  act.  Moreover, 
among  prostitutes  and  female  criminals  there  is  no  lack  of  lovers 
of  martyrization,  of  flagellation,  even  to  the  drawing  of  blood,  of 
tyrannical  treatment,  and  of  the  initiation  of  children  into  the 
mysteries  of  sex. 

[For  a  detailed  account  of  Sadism  and  Masochism,  see  von 
Krafft.-Ebin(fs  "  Psychopathia  Sexualis.  These  particular  perver- 
sions, common  in  men,  are  rare  in  women ;  hence  but  passing  allu- 
sion is  made  to  them  in  the  present  work.] 

Lombroso  records  on  account  of  its  rarity  a  case  of  masochism 
observed  by  him  in  a  woman  thirty-five  years  of  age,  who  liked  being 
whipped. 

Moraglia  reports  a  remarkable  instance  of  sexual  perversion  in  a 
girl  of  eighteen,  who  preferred  to  coitus,  masturbation  associated 
with  the  stimulating  influence  of  the  odor  of  male  urine  ;  this  peculiar 
form  of  irritability  was  so  powerful  as  to  drive  the  girl  to  mastur- 


THE  SEXUAL  EPOCH  OF  THE  MENARCHE.  195 

bation  in  public  urinals,  notwithstanding  the  risk  of  arrest,  which 
indeed  often  occurred. 

According  to  Carlier,  there  are  four  or  five  brothels  in  Paris 
which  are  not  infrequently  visited  by  rich  ladies  in  search  of  triba- 
distic  enjoyments,  and  ladies  of  "  high  life "  assemble  there  for 
communal  orgies ;  it  is  noteworthy  that  prostitutes  surrender  them- 
selves for  such  purposes  to  these  women  who  are  outside  their  own 
circle  with  great  reluctance,  and  only  for  a  very  high  fee. 

Speaking  generally,  however,  sexual  perversion  is  rarer  and 
less  intense  in  women  than  in  men.  This  fact  is  explained  by 
Lombroso  on  the  ground  that  the  erotic  element  in  women's  nature 
is  less  active,  and  that  women  are  less  often  affected  by  epilepsy, 
the  principal  source  of  these  anomalies.  In  cases  in  which  the 
genital  organs  are  healthy  we  must,  with  Westphal,  conclude,  with 
reference  to  contrary  sexual  sensation,  that  the  abnormal  sexual 
feelings  have  a  cortical  origin. 

From  von  Maschka's  elaborate  account  of  unnaitural  offences,  in 
his  Handbook  of  Forensic  Medicine,  we  abstract  the  following  pas- 
sage relating  to  the  female  sex :  "  Lascivious  procedures  liable 
under  certain  circumstances  to  legal  punishment  may  consist : 
I.  In  handling  or  other  manipulation  of  the  genitals,  without  actual 
intercourse.  If  the  genital  organs  of  a  female  have  merely  been 
gently  handled,  without  any  more  violent  manipulations,  we  shall 
not,  as  a  rule,  either  in  the  case  of  children  or  of  adults,  find  any 
local  changes  as  a  result ;  contrariwise,  if  the  handling  has  been 
rough  and  brutal,  if  the  fingers  have  been  forcibly  thrust  within 
the  vulval  cleft,  or  if  the  pudendum  has  been  pulled  and  rent,  we 
may  expect  to  find  excoriations,  redness,  swelling,  laceration  of  the 
hymen,  or  even  of  the  vagina  and  the  perineum.  2.  In  licking  the 
female  genitals  (cunnilingere).  An  analogous  process  also  effected 
by  members  of  the  female  sex,  whether  children  or  adults,  is 
irrumare,  id  est,  penem  in  os  arrigere;  fellare,  id  est,  vel  labiis  vel 
lingua  pcrfricandi  atque  exsugendi  officium  penis  prccstare.  3.  In 
introduction  of  the  membrum  virile  into  the  rectum,  either  of  chil- 
dren or  of  adults,  paederasty.  That  this  form  of  sexual  gratification 
is  not  infrequently  practiced  upon  women  has  been  pointed  out 
especially  by  Parent-Dnchatelet,  and  is  asserted  by  von  Maschka 
from  personal  knowledge  of  cases  in  which  it  has  occurred. 

Tribadism  and  Lesbian  love,  unnatural  vice  practiced  by  two 
individuals  of  the  female  sex,  occur,  according  to  von  Maschka's 
description  in  the  following  manner:  a.)  By  masturbation,  either 
one  person  gratifying  the  other  by  manipulation,  or  mutual  mastur- 
bation. In  a  case  of  this  kind  recorded  by  Tardicu,  a  wife  still 
young  repeatedly,  and  by  day  as  well  as  by  night,  introduced  her 


196  THE  SEXUAL  LIFE  OF  WOMAN. 

finger  deeply  into  the  vagina  or  the  rectum  of  her  little  girl,  moving 
it  about  there  sometimes  for  as  long  as  an  hour.  According  to  the 
child's  account,  the  mother  herself  at  these  times  was  in  a  con- 
dition of  excitement,  no  doubt  sexual,  which  she  gratified  in  this 
manner.  In  another  case,  several  older  girls  engaged  with  their 
own  fingers  and  tongues  in  lascivious  practices  with  the  genital 
organs  of  a  little  girl  of  seven.  According  to  Krausold,  among 
female  prisoners  such  "  forbidden  friendships  "  are  extremely  com- 
mon, formed  for  the  purpose  of  mutual  masturbation,  and  in  con- 
nection with  which  the  bitterest  jealousy  and  the  most  ardent  love 
are  exhibited,  b.)  With  the  assistance  of  an  enlarged  clitoris, 
with  which  one  woman  performs  the  sexual  act  by  introducing  the 
organ  within  the  vagina  of  another.  In  France  in  the  nineteenth 
century  a  woman  is  said  to  have  lived  whose  genital  organs  were 
so  formed  that,  on  the  oroe  hand,  as  a  woman  she  played  the  passive 
part  in  intercourse  with  men,  and,  on  the  other  hand,  was  able  to 
give  sexual  gratification  to  women  by  assuming  the  active  part  of 
the  male,  c.)  By  the  employment  of  an  artificial  membrum  virile. 
This  mode  of  obtaining  satisfaction  of  sexual  desire  was  known 
already  to  the  ancients,  and  such  a  priapus  was  by  the  Greeks  termed 
ohados.  The  fact  that  such  articles  are  manufactured  and  sold, 
affords  sufficient  proof  that  their  use  is  not  unknown  in  our  own 
day.  Von  Maschka  describes  such  priapi  as  being  made  of  india 
rubber,  of  the  size  and  shape  of  an  erect  penis,  perforated  longi- 
tudinally and  fitted  at  the  lower  end  with  a  testicle-like  attachment, 
to  be  filled  with  warm  water  or  milk,  so  that  by  squeezing  it  an 
ejaculation  can  be  counterfeited.  This  priapus  is  also  so  constructed 
that  it  can  be  attached  to  the  body  by  means  of  a  girdle  and  can 
thus  be  employed  for  the  gratification  of  another  individual. 

We  have  already  referred  to  sodomy,  unnatural  intercourse  with 
the  lower  animals.  Von  Maschka  gives  several  instances  of  this, 
which  we  have  previously  mentioned,  and  states  also  that  some 
years  before,  during  his  stay  in  Paris,  a  female  was  accustomed  to 
hold  a  secret  exhibition,  the  entry  to  which  cost  ten  francs,  and  at 
which  she  had  sexual  intercourse  with  a  bulldog  trained  for  the 
purpose. 

According  to  Lombroso,  even  at  the  present  day,  the  inmates  of 
licensed  brothels  frequently  hold  exhibitions,  for  admission  to  which 
a  fee  is  charged,  of  tribadistic  couples  in  poses  plastiques,  and  of 
another  prostitute  in  coitus  caninus. 

In  his  widely-celebrated  work  on  Psychopathic:  Sc.vualis,  von 
Krafft-Ebing  discusses  these  morbid  sexual  processes  in  women. 
We  select  certain  data  from  his  exposition.  Regarding  the  con- 
genital morbid  phenomenon  of  the  lack  of  sexual  feeling  in  women, 


THE  SEXUAL  EPOCH  OF  THE  MENARCHE.  197 

as  contrasted  with  perversion  of  sexual  feeling,  and  the  sexual 
impulse  toward  an  individual  of  the  same  sex  (antipathic  sexual 
feeling),  von  Krafft-Ebing  writes:  "The  woman-loving  woman 
feels  herself  sexually  to  be  a  man,  she  rejoices  in  the  exhibition' of 
courage,  of  masculine  sentiments,  since  these  characteristics  make 
the  man  desirable  to  the  woman.  The  female  urning™  therefore, 
likes  to  have  her  hair  cut  short  and  her  clothes  of  a  masculine  cut; 
and  one  of  her  greatest  pleasures  is  when  opportunity  offers  to 
appear  in  male  attire.  Her  ideals  are  notable  feminine  personalities, 
distinguished  by  spirituality  and  energy ;  in  the  theatre  and  in  the 
circus,  it  is  only  .the  female  performers  that  attract  her  interest; 
and  in  the  same  way,  in  collections  of  pictures  and  statues,  it  is 
only  the  representations  of  women  that  awaken  her  aesthetic  sense 
and  her  sensibility."  Von  Krafft-Ebing  insists  that  in  nearly  all 
cases  of  antipathic  sexual  feeling  in  which  a  family  history  was  at- 
tainable, that  history  was  found  to  exhibit  instances  of  neuroses,  psy- 
choses, stigmata  of  degeneration,  etc.  In  hysteria,  according  to 
this  author,  the  sexual  life  is  especially  often  abnormal ;  in  cases 
with  neuropathic  inheritance,  one  may  say  always :  "All  possible 
anomalies  of  the  sexual  functions  occur  in  such  cases,  with  the 
utmost  variety  and  the  strangest  commingling,  based  upon  heredi- 
tary degenerative  processes,  and  accompanied  by  moral  imbecility 
in  its  most  perverse  manifestations.  *  *.  Frequently,  in  hys- 

terical subjects,  the  sexual  life  is  morbidly  excitable.  This  excite- 
ment may  be  intermittent  (?  menstrual).  Shameless  prostitution 
may  result,  even  in  married  women.  In  cases  of  a  milder  type,  the 
sexual  impulse  is  exhibited  in  the  form  of  onanism,  nude  perambu- 
lations about  the  room,  wearing  of  male  attire,  etc.  In  cases  of 
hysterical  mental  disorder,  the  morbidly  excited  sexual  life  may 
manifest  itself  in  the  form  of  maniacal  jealousy,  baseless  complaints 
against  men  of  indecent  assault,  hallucinations  of  coitus,  etc.  Some- 
times there  may  be  frigidity,  with  lack  of  sexual  pleasure,  commonly 
due  to  genital  anaesthesia." 

Incest  in  women,  dependent  upon  psychopathic  causes,  is  also 
alluded  to  by  von  Krafft-Ebing;  it  occurs  in  those  in  whom  a  partial 
imbecility  that  leaves  the  sense  of  modesty  undeveloped  is  combined 
with  eroticism.  Thus,  a  case  reported  by  Schurmayer  is  mentioned, 
in  which  a  mother  had,  or  attempted,  intercourse  with  her  son, 
aged  five  and  one-half  years ;  and  again  a  case  reported  by  Lafarque, 
in  which  a  girl  of  seventeen  laid  her  thirteen-year-old  brother  on 
herself  for  the  gratification  conjnnctionis  membrorum,  while  simul- 

85 This  word  urning,  used  to  denote  individuals  exhibiting  this  particular 
type  of  homosexuality,  belongs  to  the  terminology  now  generally  adopted  by 
writers  on  sexual  pathology,  and  has  been  used  by  English  writers  on  the 
subject  —  Havelock  Ellis,  for  instance. 


198  THE  SEXUAL  LIFE  OF  WOMAN. 

taneously  masturbating  her  brother;  Magnan's  case,  an  unmarried 
woman  twenty-nine  years  of  age,  who  could  hardly  resist  the  impulse 
toward  copulation  with  her  nephews  as  long  as  they  were  quite 
young;  Lcgrand's  cases,  in  one  of  which  a  girl  fifteen  years  of 
age  seduced  her  brother  to  the  performance  of  all  possible  sexual 
excesses  on  her  body;  another,  a  married  woman  aged  thirty-five, 
who  committed  incest  with  her  eighteen-year-old  brother ;  and  a 
third,  a  mother  aged  thirty-nine,  who  committed  incest  with  her  son. 

According  to  Moll,  women  who  suffer  from  antipathic  sexual  sen- 
sation afe,  in  many  cases,  married ;  it  appears,  however,  that  for 
the  most  part  they  have  no  inclination  to  marry.  •  In  isolated  cases 
there  may "  exist  a  psychical  hermaphroditism,  the  woman  thus 
affected  having  sexual  inclination  both  towards  men  and  towards 
women.  In  the  case  of  homosexual  women,  normal  intercourse 
appears  not  to  furnish  complete  satisfaction.  As  regards  fetichistic, 
masochistic,  and  sadistic  inclinations  on  the  part  of  women  with  an- 
tipathic sexual  sensation,  Moll  was  unable  to  obtain  any  trustworthy 
information.  Sometimes  in  women  the  perverse  sexual  impulse 
appears  periodically,  being  then  often  associated  with  the  appearance 
of  other  psychical  abnormalities.  In  some  women  the  perverse 
impulse  is  especially  active  at  the  menstrual  periods ;  whilst  at  other 
times  these  subjects,  even  though  not  quite  sexually  normal,  are 
still  very  much  quieter.  Antipathic  sexual  sensation  in  women. may 
depend  upon  inherited  predisposition,  and  may  often  be  traced  back 
to  a  very  early  age.  In  many  cases  an  exciting  cause  may  be 
demonstrated. 

Mantegasza,  who  relates  that  homosexual  practices  are  common 
among  the  inmates  of  harems,  believes  that  antipathic  sexual  feeling 
is  readily  curable  in  women  soon  after  marriage,  but  that  later  a 
cure  is  rare. 

A  perverse  form  of  sexual  gratification  sometimes  met  with  in 
women  is  flagellation.  By  chastisement  with  birches,  straps,  or  whips 
on  the  bare  buttocks,  the  nerves  of  the  sexual  apparatus  are  stimu- 
lated, and  these  organs  become  congested,  with  an  effect  resembling 
that  of  onanism.  Such  flagellation  was  practiced  by  the  wanton 
ladies  of  ancient  Rome.  In  the  Middle  Ages,  hysterical  women 
derived  great  pleasure  from  the  stimulatory  effect  of  whippings. 
It  is  reported  of  Catharine  de  Medici,  that  she  had  herself  whipped, 
and  that  she  delighted  in  seeing  the  ladies  of  her  court  undergoing 
similar  treatment.  In  the  present  day  many  women  derive  intense 
sexual  pleasure  from  being  birched  by  their  lovers  on  bared  portions 
of  their  bodies.  In  Paris  and  other  large  towns  there  are  special 
places  of  resort  for  those  who  pursue  this  form  of  perverse  sexual 
gratification.  Sometimes  such  women  are  only  the  active  fouct- 
teuses  for  worn-out,  perversely-feeling  men. 


199 

Among  the  Greeks,  a  woman  who  had  remained  barren  during 
the  early  years  of  marriage  would  visit  the  temple  of  Juno,  in  order 
to  receive  from  a  priest  of  Pan  the  gift  of  fertility.  She  stripped 
naked,  and,  while  thus  exposed  to  the  flagellant  priests,  she  received 
all  over  the  back  of  her  body  numerous  blows  inflicted  with  thongs 
of  a  he-goat's  hide  —  this  process  being  supposed  to  induce  fertility. 
The  object  of  this  form  of  flagellation  would  appear  to  be  to  induce 
an  increase  of  sexual  desire. 

Sexual  neurasthenia  is  defined  by  Eulenburg  as  a  neuropsychosis 
of  chronic  course,  manifesting  itself  chiefly  in  the  form  of  excessive 
irritability  of  the  sensory  and  psychoserisory  neuron-systems,  in 
association  with  excessive  tendency  to  exhaustion  of  the  motor  and 
psychomotor  neuron-systems.  This  exhaustion  occurs  especially  in 
relation  to  the  genital  system,  in  which  we  see  exhibited  the  phe- 
nomena of  irritable  weakness,  of  increased  excitability  combined 
with  increased  tendency  to  fatigue  of  the  genital  nerve  apparatus  — 
such  chronic  morbid  disturbances  are,  according  to  this  author,  com- 
paratively rare  in  women,  that  is  to  say,  the  developed  typical  picture 
of  the  disease  does  not  occur  in  women,  or  occurs  very  rarely. 
Among  168  patients  suffering  from  sexual  neurasthenia,  only  six 
were  women.  Two  of  these  latter  were  addicted  to  masturbation, 
and  in  the  anatomical  sense  both  were  still  virgins ;  the  rest  were 
married  women,  not  receiving  sufficient  sexual  gratification  in  their 
married  life,  two  of  these  were  probably  also  addicted  to  mastur- 
bation, two  indulged  in  homosexual  practices. 

Onanism,  according  to  Eulenburg,  is  the  cause  of  sexual  neuras- 
thenia in  women  as  well  as  in  men.  If,  however,  among  the  relatively 
very  large  number  of  women  addicted  to  masturbation,  there  appears 
to  be  such  a  very  small  proportion  of  instances  of  sexual  neuras- 
thenia, this  depends  on  the  fact  that  from  the  nature  of  onanism  in 
women  the  physical  and  also  as  a  rule  the  psychical  consequences  are 
as  a  whole  apt  to  be  much  less  severe  than  those  arising  from  similar 
practices  in  men ;  but  it  depends  also  on  the  circumstances  that 
neuromental  abnormalities  of  other  kinds  and  denoted  by  other 
names,  such  as  dyspareunia,  vaginismus,  sexual  hysteria,  nympho- 
mania,  feminine  sadism,  and  tribadism,  are  apt  to  arise  in  conse- 
quence of  onanism.  As  regards  onanism,  so  also  may  it  be  in  regard 
to  sexual  excesses  and  aberrations  in  general ;  they  may  be  on  the 
one  hand  causes,  but  on  the  other  symptoms  and  sequelae,  of  sexual 
neurasthenia.  Early-acquired  or  inherited  homosexual  tendencies 
and  habits  may,  as  Eulenburg  further  points  out,  lead  to  sexual 
neurasthenia  only,  but  then  very  easily,  when  such  individuals  have 
allowed  themselves,  against  their  nature  but  in  obedience  to  conven- 
tional points  of  view  and-  to  the  advice  of  the  relatives,  to  be  per- 
suaded into  marriage.  That  sexual  abstinence  alone  is  competent  to 
induce  sexual  neurasthenia  must  be  dismissed  as  a  fable. 


H.  THE  SEXUAL  EPOCH  OF  THE  MENACME. 


By  the  term  menacnte  I  designate  the  culmination  of  the  sexual 
development  of  woman,  during  which  the  processes  of  reproduction, 
copulation,  conception,  pregnancy,  parturition,  and  lactation  occur. 

The  processes  of  puberty  in  woman  are  fully  completed  at  the  age 
of  from  eighteen  to  twenty  years,  so  that  from  this  time  forward 
she  is  fully  equipped  for  the  performance  of  her  sexual  duties.  The 
first  act  in  the  fulfilment  of  these  duties  is  copulation,  which  in 
civilized  countries  is  in  the  great  majority  of  women  first  undertaken 
at  the  commencement  of  married  life.  The  average  age  at  marriage 
in  the  women  of  this  part  of  the  world  is  22;  but  marriages  at 
an  earlier  age  are  very  common,  and  in  many  circles  of  society  the 
average  age  is  as  low  as  20.  The  fullest  maturity  of  sexual  ac- 
tivity in  women  occurs,  however,  in  the  thirty-second  year  of  life,  this 
being  the  year  in  which  on  the  average  the  maximum  fertility  is 
attained. 

At  the  menacme,  the  beauty  and  energy  of  women  attain  their 
fullest  evolution,  her  sexual  characteristics  their  strongest  develop- 
ment. It  is  this  period  of  life,  however,  that  entails  the  greatest 
dangers  to  beauty  and  health  in  connection  with  the  functions  of 
the  genital  organs.  Copulation,  the  first  act  of  sexual  intercourse 
with  the  male,  often  produces  in  the  female  injuries  from  \vhich  she 
never  completely  recovers.  Gonorrhceal  infection  has  been  a  source 
of  unspeakable  miseries  to  women.  Motherhood  itself  entails  the 
risk  of  a  great  number  and  variety  of  illnesses,  which,  as  puerperal 
sequelae,  affect  this  phase  of  woman's  life.  The  struggle  for  exist- 
ence, in  which  woman  at  her  prime  is  also  involved,  and  the  fulfil- 
ment of  duties  to  husband  and  children,  further  lead  to  the  produc- 
tion of  a  series  of  changes,  both  physical  and  mental,  in  the  feminine 
organism,  which  influence  all  the  functions. 

The  great  characteristic  of  this  epoch  is  maternity.  In  maternity 
the  fully  developed  woman  lives  and  has  her  being,  but  to  maternity 
also  she  often  succumbs  as  a  sacrifice  to  the  fulfilment  of  her  natural 
functions.  Inasmuch  as  in  this  sexual  phase  the  functions  of  the 
genital  organs  are  of  greater  importance,  to  the  same  degree  is 
enhanced  the  importance  of  the  mutual  relations  between  these 
organs  and  the  other  organs  of  the  female  body. 

[200] 


THE  SEXUAL  EPOCH  OF  THE  MENACME.  201 

Another  influence  of  fundamental  importance  in  the  sexually 
mature  woman  is  that  of  the  sexual  impulse,  the  force  of  which  is 
at  times  overwhelming,  so  that  its  gratification  is  sometimes  sought 
without  regard  for  the  consequences  to  married  and  family  life. 

The  physiology  and  pathology  of  the  menacme  coincides  with  the 
normal  processes  and  pathological  changes  respectively  of  the  female 
genital  organs  consequent  on  their  functional  activity  as  organs 
of  sexual  sensation  and  of  reproduction.  Woman  as  wife  and 
mother  stands  at  the  climax  of  her  existence. 

In  a  quite  astonishing  manner,  however,  many  of  the  advocates  of 
the  modern  movement  for  the  emancipation  of  women  contest  the 
significance  of  maternity  to  women. 

A  modern  authoress  and  supporter  of  women's  rights,  Ellen  Key, 
avows  that  she  was  in  error  when  at  an  earlier  date  she  "  regarded 
maternity  as  the  central  point  in  woman's  existence."  She  asserts 
that  it  lies  within  the  sphere  of  a  woman's  individual  rights,  as  of 
a  man's,  to  reject  marriage,  or  to  accept  marriage  while  rejecting 
maternity.  "  The  grounds  for  the  rejection  of  maternity  may  as 
well  be  deeply  altruistic  as  deeply  egoistic.  It  lies  within  the  sphere 
of  individual  rights  to  dispense  with  love  or  with  maternity  when 
either  is  regarded  or  both  are  regarded  from  this  point  of  view. 
It  is  entirely  within  a  woman's  rights  to  transform  herself  into  a 
member  of  the  '  third  sex,'  the  sex  of  the  worker  bee,  of  the  neuter 
ant,  if  she  finds  therein  her  greatest  pleasure.  *  *  *  Women 
exist  in  whom  erotic  feeling  is  totally  atrophied ;  there  are  yet  others 
who  fail  to  find  in  intercourse  with  the  modern  man  that  soulful 
and  deep  erotic  harmony  which  they  rightly  desire;  and  there  are 
others  still  more  numerous  who  desire  love,  but  not  maternity, 
which  indeed  they  dread." 

A  celebrated  German  authoress  of  the  present  day,  Gabrlele 
Renter,  refers  in  similar  terms  to  the  justifiable  fear  with  which 
so  many  aspiring  and  hard-working  women  regard  maternity,  "  the 
perpetual,  watchful,  emotional  dread  of  motherhood,  a  dread  which 
causes  them  to  turn  at  bay.  A  dread,  a  hatred,  it  is,  which  has 
grown  so  strong,  so  active,  that  one  might  almost  regard  it  as  an 
obscure  perverse  instinct,  awakened  and  developed  and  strengthened 
by  bitter  necessity.  It  is  as  if  in  the  innermost  recesses  of  their 
nature  such  women  had  a  belief  that  should  they  pay  their  tribute 
to  sex  they  would  loose  all  the  energy,  clearness,  and  brightness  of 
mind,  by  means  of  which  they  have  raised  themselves  above  the  level 
of  their  sex.  And  perhaps  women  of  a  certain  type  are  justified 
in  this  fear." 

Fortunately,  however,  the  woman  who  does  not  prize  maternity 
still  remains  an  exception.  The  great  instinct  for  the  preservation 


.LIEGE  OF-.J3STEC.fAT 


THE  SEXUAL  LIFE  OF  WOMAN. 

of  the  species,  which  nature  has  planted  deeply  in  every  human 
being,  still  as  a  rule  in  women  remains  much  more  powerful  than 
the  instinct  of  self-preservation  at  every  one  else's  expense- — more 
powerful  than  such  self-sufficient  egoism.  And  now  as  ever  it  is 
the  duty  of  humanity  to  educate  women  for  maternity  from  her  youth 
upward,  so  that  she  is  in  every  way  fitted  for  the  supreme  duty  of 
her  sexual  nature,  the  renewal  of  life  from  generation  to  generation. 

Against  the  significance  and  importance  of  maternity  to  woman, 
the  mountainous  waves  of  the  movement  for  the  emancipation  of 
women  dash  themselves  as  vainly  as  against  the  solid  rock.  Much 
justification  may  be  found  for  the  efforts  of  women  in  modern 
civilized  communities  to  engage  in  departments  of  activity  to  which 
hitherto  men  only  have  been  admitted;  and  as  regards  the  intellectual 
capacity  of  women  we  may  acknowledge  their  competence  for 
the  higher  scientific  professions ;  but  while  admitting  this  we  must 
hold  firmly  to  the  physiological  standpoint  and  must  more  espe- 
cially bear  in  mind  the  sexual  life  of  woman.  Such  professions  only 
are  suitable  for  a  woman  as  do  not  entail  a  restriction  of  the  sphere 
of  her  reproductive  activity,  a  hindrance  to  her  principal  duty,  that 
of  maternity,  an  interference  with  the  discharge  of  her  obligations 
to  husband  and  children,  or  a  diminution  of  her  domestic  value  and 
an  evasion  of  her  responsibilities  in  family  life.  As  L.  von  Stein 
so  justly  remarks,  the  woman  who  spends  the  whole  day  at  a  desk, 
in  the  law  courts,  or  in  a  house  of  assembly,  may  be  a  most  honorable 
and  most  useful  individual,  but  she  is  no  longer  a  woman,  she  can- 
not be  a  wife,  she  cannot  be  a  mother.  In  the  condition  of  our 
society,  the  emancipation  of  woman  is  in  its  very  nature  the  negation 
of  marriage. 

We  may  not  agree  with  the  great  misogynist,  Schopenhaiir,  in  his 
depreciation  of  the  female  sex,  or  in  his  assertion  that  woman  exists 
simply  and  solely  for  the  propagation  of  the  species,  and  that  "  her 
life  should  therefore  flow  more  quietly,  more  inconspicuously,  and 
more  gently  than  that  of  man  toward  its  goal ;"  nor  need  we  regard 
as  justified  the  severe  sentence  of  the  philosopher,  E.  von  Hartmann, 
that  from  the  moral  standpoint,  "  the  greater  number  of  women  pass 
the  whole  of  their  lives,  in  a  state  of  minority,  and,  therefore,  to 
the  end  stand  in.  need  of  supervision  and  guidance ;"  but  the  state- 
ment made  by  Friedr.  Nietsche  in  his  book  Also  sprach  Zarathnstra 
deserves  acceptation,  "  Everything  in  woman  is  a  riddle,  and  every- 
thing in  woman  has  its  answer:  it  is  called  pregnancy,"  and  again, 
"  For  woman,  man  is  only  the  means ;  the  end  is  always  the  child." 

Unsearchable  in  its  judgments,  nature  has  imposed  on  woman  alone 
the  consequences  of  the  act  of  generation ;  man  has  the  pleasure, 
but  not  the  labor  and  the  pain.  We  might  indeed  regard  as  highly 


/  '/I  E  U 

1 0    H  ft  3  J  J  0 


THE  SEXUAL  EPOCH  OF  THE  MENACME.  203 

unjust  the  distribution  of  the  roles  in  the  process  of  reproduction, 
were  it  not  that  in  a  mother's  love  and  a  mother's  joys,  woman  finds 
a  compensatory  solace.  The  man's  part  is  a  much  easier  one  and 
costs  far  less  than  that  of  woman ;  with  the  gratification  of  his  sexual 
desire,  man  shakes  off  any  further  responsibility,  whereas  the 
woman's  body  becomes  the  workshop  in  the  wonderful  act  of  crea- 
tion of  a  new  human  life. 

Maternity,  says  Lombroso,  is  the  characteristic  function  of  the 
female  sex,  upon  which  rests  her  whole  organic  and  physical  varia- 
bility, and  this  function  is  indeed  throughout  of  an  altruistic  nature. 
Although  there  is  a  certain  antagonism  between  the  sexual  impulse 
and  maternity  —  according  to  I  card,  the  sexual  impulse  is  extin- 
guished in  women  during  pregnancy, —  still,  maternity  appears  to 
depend  upon  sexual  perceptions.  For  instance,  the  act  of  suckling 
the  infant  often  arouses  voluptuous  sensations,  and  Icard  mentions 
a  case  in  which  a  woman  permitted  fertilization  to  occur  solely  on 
account  of  the  pleasure  obtained  by  suckling.  The  anatomical 
cause  of  this  fact  is  to  be  found  in  the  connections  between  the  nipple 
and  the  uterus  by  way  of  the  sympathetic  nervous  systeir.  *  *  * 
It  is  likewise  probable  that  in  the  happy  feeling  of  matem.'v  there 
intermingle  very  gentle  voluptuous  sensations  derived  from  the 
genital  organs.  According  to  Bain  also,  very  delicate  sensations  of 
contact  form  an  element  in  maternal  love. 

The  epoch  of  the  menacme  is  that  in  which,  independently  of 
maternity,  the  sexual  impulse  often  becomes  so  powerful  in  woman 
as  to  be  entirely  dominant.  The  problems  relating  to  marriage  and 
to  the  sexual  position  of  woman,  so  widely  discussed  at  the  present 
day,  are,  therefore,  of  especial  importance  in  regard  to  women  at 
this  period  of  life.  The  forcible  repression  and  control  of  the  sexual 
impulse  inculcated  by  moral  and  religious  ordinances  are  now,  ac- 
cording to  the  modern  leaders,  both  male  and  female,  of  the  woman's 
movement,  to  be  abandoned ;  and  it  is  loudly  asserted  that  every 
woman  has  the  same  right  as  man  to  physical  love  and  the  happiness 
it  produces.  Hence,  free  love  is  demanded.  "  Freedom  in  love, 
freedom  for  love  —  this  is  what  the  dignity  of  the  human  race  de- 
mands," asserts  the  authoress  of  a  book  recently  published  (EHsa- 
beta  von  Steinborn,  The  Sexual  Position  of  Woman}.  With  laws 
for  the  regulation  of  marriage,  this  section  of  the  women's  rights 
party  will  have  nothing  to  do.  A  truly  good  and  honorable  man, 
they  contend,  has  as  little  need  of  laws  to  regulate  his  amorous 
relations  as  he  has  of  laws  against  murder  and  theft.  In  the  first 
place,  love,  the  sexual  relation  between  man  and  woman,  must  be 
free,  and  humanity,  freed  from  vexations  and  needless  control,  will 
then  seek  and  find  the  proper  path,  even  if  at  the  expense  of  a  few 


204 


THE  SEXUAL  LIFE  OF  WOMAN. 


errors  by  the  way.  Only  after  this  unrestrained  sexual  intercourse 
has  lasted  for  a  long  time,  will  free  marriage  become  the  rule. 
"  Out  of  this  phase  will  develop  the  monogamic  system  willed  by 
God,  for  which,  in  its  most  ideal  form,  we  are  not  yet  sufficiently 
ripe."  It  is  hardly  necessary  to  discuss  in  detail  the  general  dele- 
terious influence  of  such  unlimited,  unregulated  free  love  upon  the 
community,  upon  human  society  as  a  whole,  to  describe  the  results 
of  free  loye,  to  attempt  to  realize  the  chaos  which  it  would  bring 
about  in  the  social  relations  of  civilized  humanity.  We  must  rather 


Prepuce  of  the 
clitoris 


Anterior  commis- 
sure of  the  vi  iva 


Labium   majus 


Rima  urogenitalis, 
or  vulval  cleft 


Perineum 


Anus 


FIG.  48. —  The  female  pudendum,  or  vulva,  with  the  labia  majora.  The 
vulval  clett.  Female  perineum.  Mons  veneris,  with  the  pubic  hair. 
(From  Toldt :  Atlas  of  Human  Anatomy. — Rebman  Company,  New  York.) 

indicate  it  as  desirable  from  the  medical  standpoint  also,  that  such  a 
change  in  general  domestic  economy  shall  be  aimed  at  as  will  enable 
the  great  majority  of  women  to  share  in  married  life  and  family 
happiness,  and  thus  making  allowance  both  for  human  nature  and 
the  demands  of  social  life,  to  effect  a  true  harmony  between  sexual 
morality  and  sexual  practice. 


THE  SEXUAL  EPOCH  OF  THE  MENACME. 


205 


We  must  point  out  that  in  so  far  as  the  modern  woman's  move- 
ment aims  at  dispensing  with  man  and  at  basing  the  entire  life  of 
woman  upon  the  independent  ego,  that  movement  is  in  opposition 
to  nature  and  its  eternal  laws.  A  woman  who  thus  seeks  the  solu- 
tion of  the  woman's  question  in  the  direction  of  freedom  and  in- 
dependence is  one  who  endeavors  to  avoid  the  burthen  of  woman- 
hood. She  desires  to  escape,  always  from  guardianship,  often  from 
maternity,  and  usually  from  the  restrictions,  the  unselfishness  of 
womanhood.  But  none  the  less  does  she  remain  unable  to  escape 
from  her  femininity. 

"  The  true  significance  of  woman,"  insists  Laura  Marholm  in 
opposition  to  the  modern  tendency,  "  has  at  all  times  consisted  rather 
in  what  she  is  than  in  what  she  performs,  and  it  is  precisely  in 


Prepuce  of  th.: 
clitoris 

Glans   clitoridis 


Fraenun    of    the 
clitoris 

Labium      minus, 
or  nympha 


Vestibule    of  the 
vagina 


Carunculae 
myrtiformes 

Orifice  of  the  duct 
of  Bartholin's 
gland 

Fossa       navicularis 
(of  the  vulva) 

Fourchette,    or  fraenu- 
lum  pudendi 


Anterior  commissure 
of  the  vulva 


,'  Libium  majus 


Orifice        of 
Skene's  tubule 
or        para-ure- 
thral  duct 
External       ori- 
fice of  the  ure- 
thra 
Urethral  ridge 


Anterior    vagi- 
nal column 

Vaginal  orifice 


Posterior  vaginal 
column 


Posterior  commissure 
of  the  vulva 


FIG.  49. — Vestibule  of  the  vagina,  with  the  labia  minora  ornyrnphae,  the 
vaginal  and  urethral  orifices,  and  the  glans  clitoridis.  (From  Toldt:  Atlas 
of  Human  Anatomy. — Rebman  Company,  New  York.) 

the  former  point  that  the  women  of  the  present  day  seem  so  un- 
usually wanting.  Their  performances  are  indeed  many  and  various, 
they  study  and  they  write  innumerable  books,  they  are  the  directors 
or  principals  of  all  possible  concerns  and  collect  funds  for  every 
possible  object,  they  wear  doctors'  gowns,  conduct  agitations,  and 
found  clubs,  and  they  come  continually  more  and  more  into  publicity. 
And  yet  their  public  significance  is  after  all  diminished.  The 
greater  the  influence  of  woman  in  the  mass  and  as  a  numerical 


206  THE  SEXUAL  LIFE  OF 

majority,  the  less  is  her  influence  as  an  individual,  the  smaller  is  the 
triumph  of  her  sex.  She  herself  has  induced  man  to  sound  the 
trumpet  note  of  the  abhorrence  of  women.  Tolstoi  in  The  Kreuzer 
Sonata,  Strindbcrg  in  numerous  dramas,  Huysmans  in  En  Menage, 
write  in  this  strain ;  and  in  the  works  of  many  lesser  luminaries  we 
encounter  this  mistrust  of  love.  *  *  *  The  modern  system  of 
education  for  girls,  with  its  polyglossia  and  polymathy,  favors  a 
superficial  development  of  the  understanding,  and  produces  women 
who  are  pretentious  without  being  profound." 

Feminine  beauty  suffers  during  the  menacme  from,  the  stress 
of  the  demands  made  on  the  sexual  activity  as  well  as  on  the  func- 
tional capacity  of  the  individual.  Repeated,  rapidly  succeeding  preg- 
nancies and  confinements  impair  the  beauty  of  the  breasts  and  the 
abdomen,  the  figure  and  the  carriage.  In  consequence  of  suckling, 
the  breasts,  hitherto  firm  and  elastic,  usually  become  more  or  less 
pendent  and  wrinkled,  sometimes  also  flabby  and  inelastic,  some- 
times nodular.  Diseases  of  the  genital  organs  and  the  disorders  of 
the  general  health  dependent  thereon,  leave  disfiguring  wrinkles  in 
the  face  and  other  traces  in  the  whole  structure  of  the  body.  Toil, 
anxiety,  and  grief  also  write  their  horrible  marks  deeply  on  the  ap- 
pearance. The  mature  working-class  woman,  through  sharing  in 
masculine  labors,  through  long-continued  muscular  exertion,  and 
through  neglect  of  bodily  care,  frequently  assumes  in  her  features, 
her  carriage,  her  figure,  and  her  whole  appearance,  a  rather  mascu- 
line type. 

The  beauty  and  the  youthful  freshness  of  girls  belonging  to  the 
labouring  classes  seldom  endure  for  long  after  the  menarche,  and 
in  cases  in  which  the  environment  is  one  of  poverty, they  last  through 
a  very  short  part  only  of  the  epoch  of  the  menacme.  The  early  ap- 
pearance of  wrinkles  in  the  face,  the  stiff,  angular  character  of  the 
movements,  the  ungraceful  carriage  of  the  body,  all  these  combine 
to  make  a  woman  of  five-and-twenty  who  groans  under  the  burthen 
of  toil  appear  at  the  first  glance  an  elderly  woman,  and  a  closer 
investigation  shows  what  damage  has  been  wrought  to  the  attributes 
of  beauty,  how  the  breasts  are  flabby  and  flattened,  the  belly  prom- 
inent, the  buttocks  pendulous,  the  arms  muscular. 

In  the  well-to-do  classes,  again,  at  this  period  of  life,  when  gen- 
erous diet  combines  with  insufficient  exercise,  an  abundant  deposit 
of  adipose  tissue  may  already  have  occurred,  resulting  in  a  great 
impairment  of  beauty,  the  body  and  limbs  being  enlarged,  the  gait 
and  the  carriage  correspondingly  altered  for  the  worse  —  changes 
which  seem  desirable  only  to  those  orientals  to  whom  such  obesity, 
such  exaggeration  of  femininity,  is  sexually  stimulating.  If,  how- 
ever, this  deposit  of  fat  is  not  excessive,  this  it  is  which  endows 


THE  SEXUAL  EPOCH  OF  THE  MENACME. 


207 


women  during  these  years  of  fullest  development  with  an  imposing 
appearance  and  buxom  form.  In  favourable  circumstances,  beauty 
of  this  type  may  persist  to  the  fortieth  year  of  life  and  even  be- 
yond, and  it  is  of  such  a  character  as  to  justify  the  proverb  that 
woman's  first  sexual  epoch  is  dedicated  to  love,  her  second  to  volup- 
tuousness. 


Mesovarium 
Mesosalpinx 

Ampulla  of  the  Fallo-    \ 

plan  tube 
Abdominal    ori- 
fice of  the 
Fallo- 
pian 
tube 


Anterior,  straight,  or  attached  border  of  the  ovary 
l  Isthmus  of  the  Fallopian        Fundus  of 

I  tube 

Ligament    of    the 

ovary 

I 


the  uterus 


Fallopian  tube 

Ligament  of  the 
I  ovary 


Round  liga- 
ment of  the 
uterus 


Fimbriae 
of  the  Fal- 
lopian tube 
Ovarian     ar-    ! 
tery  and   vein 
Superior  or  tubal 
extremity  of  the 
ovary  / 

Ovary  (external'          / 
surface)  ./ 

Posterior,  convex  or  free 
border  of  the  ovary 
Inferior  or  uterine  extremity 
of  the  ovary 


Os  externum- 
Anterior  lip  of  the  cervix. 


Body  of  the  uterus 


f"  Neck  of  the  uterus 


Fornix       of       the 
vagina 


Vaginal  portion  of 
the  cervix 


FIG  50. — The  uterus,  the  left  Fallopian  tube  and  the  left  every,  in  their  connection  with  the 
broad  ligament  of  the  uterus,  which  has  been  fully  unfolded.  Seen  from  behind.  From  a  virgin , 
aged  nineteen  years.  (From  Toldt :  Atlas  of  Human  Anatomy.—  Rebman  Company,  New 
York) 

"  Bountiful  nature,"  writes  Mantegazza,  regarding  woman  at  this 
sexual  epoch,  "  sends  to  woman  an  ingenious  engineer,  who  en- 
larges the  hills  to  mountains  and  fills  up  the  valleys  with  a  soft 
alluvium  of  fat.  The  commencing  wrinkles  disappear,  being 
smoothed  out  under  the  beneficial  influence  of  this  plastic  material ; 
the  slender,  elastic  palm-tree  stems  are  converted  into  majestic  col- 
umns of  Parian  marble ;  quality  is  replaced  by  quantity,  and  if  the  eye 
has  lost  a  few  provinces,  the  hand  has  gained  just  as  many.  *  *  * 
A  certain  number  of  chosen  women  understand  how  to  preserve  for 
as  long  as  ten  years  the  unstable  equilibrium  of  the  period  which 
separates  these  two  ages  of  life.  There  are  divine  beings  who  with 
every  oscillation  of  their  tresses  or  rocking  of  their  hips,  with 
every  undulation  of  their  bosom,  every  serpentine  movement  of  their 
limbs,  instil  desire.  *  *  *  They  constitute  our  most  intense 


208 


THE  SEXUAL  LIFE  OF  WOMAN. 


delight,  and  our  intensest  torment,  they  make  our  life  a  blessing  or 
a  curse,  they  are  the  uttermost  goal  of  human  passion,  of  human 
voluptuous  desire." 


Ampulla  of    the    Fallopian  tube ~A 

Infundibulum        of       the  " . 

Fallopian  tube 

Fimbriae   of      the  Fallo-: 
pian  tubs 

Posterior,     convex,    or    -, 
free     border  of    the 
ovary 

Internal      surface       of 
the  ovary 

Anterior,    straight,   or 
attached   border 

Ligament        of        the  -- 
ovary 

Inferior  or  uterine 
extremity  of  the 
ovary 

Posterior  or  in- 
testinal surface 
of  the  uterus 

Utero-sacral  liga- 
ment 

Os  uteri  internum 

Cavity  of    the 
cervix 

Uterovesical    - 
pouch 

Posterior    vag- 
inal fornix 

Posterior    lip   of 
the  cervix 
Pouch  of  Douglas 
Os  uteri  externum  ' 

Anterior  lip  of    the  cervix 


Suspensory  ligament  of  the 

ovary 
Superior  or    tubal    extremity    of 

the  ovary 

Bursa  ovarica 


Mesosalpinx 
__Mesovarium 


Isthmus   of    the    Fallopian 
-    tube 

£~-  Fundus  of  the  uterus 


»          ,    Anterior  or  vesical    sur- 
face of  the  uterus 


Uterine  cavity 

_.-••  Visceral   peri- 
toneum 


Urinary 
'•,    ;/  bladder 

Internal    orifice    of 

the  urethra 

Urethra 


Vaeina  /Anterior     wal' 
Vagina  j  posterior  wall 


FIG.  51. —  Female  internal  genital   organs    in    the    fully  developed    state. 
(From  Toldt :    Atlas  of  Human  Anatomy. — Rebman  Company,  New  York  ) 


Among  the  injuries  to  beauty  effected  by  pregnancy,  one  above  all 
evident  to  the  eye  is  the  almost  invariably  ensuing  change  in  the 
skin,  principally  taking  the  form  of  a  change  in  pigmentation,  with 
the  appearance  of  spots  varying  in  size  and  tint,  on  the  face  and 
especially  on  the  lips  and  the  forehead ;  there  is  greatly  increased 
pigmentation  also  of  the  areola  mammae  and  the  linea  alba,  and  in' 
addition  of  the  labia  majora  and  minora  and  of  the  anal  region.  It 
is  not  certain  whether  this  chloasma  uterinum  is  dependent,  as  Jca- 
min  assumes,  on  the  discontinuance  of  menstruation,  or,  as  Virchow 
believes,  on  changes  in  the  blood  and  the  blood-pressure.  Some- 
times also,  in  pregnant  women,  we  observe  on  the  face,  chiefly  on 


THE  SEXUAL  EPOCH  OF  THE  MENACME.  209 

the  nose  and  the  cheeks,  dilatations  of  the  small  cutaneous  vessels, 
often  associated  with  acne  nodules. 

A  permanent  disfigurement  is  caused  by  the  linea  (vel  strice}  al- 
bicantes,  white  lines  or  streaks  of  varying  length  and  resembling 
scar  tissue  in  appearance  on  the  skin  of  the  abdomen,  the  adjoin- 
ing parts  of  the  buttocks  and  thighs,  the  lower  part  of  the  front 
of  the  thorax,  and  the  mammae.  They  are  not  true  scars,  not 
being  new  formations  of  connective  tissue,  being  on  the  contrary 
dependent  on  solutions  of  continuity,  on  relative  diminution,  that  is 
to  say,  of  the  connective  tissue  layer  of  the  skin.  They  are  formed 
in  consequence  of  the  fact  that  the  connective  tissue  bundles  are  not 
able  to  keep  pace  in  their  superficial  enlargement  with  the  neces- 
sarily rapid  extension  of  the  cutis,  hence  great  meshes  appear  in 
the  former,  situate  in  the  direction  of  the  greatest  tension  of  the 
skin.  (Spietshka  and  Griinfcld}. 

Transiently  during  pregnancy,  but  in  some  cases  permanently 
also,  the  beauty  of  the  lower  extremities  is  apt  to  be  impaired  by 
enlargements  of  the  veins,  the  formation  of  varices,  and  sometimes 
also  by  oedema ;  these  conditions  depend  upon  the  hindrance  to  the 
venous  return  caused  by  the  pressure  of  the  pregnant  uterus.  Thick, 
vermicular,  bluish  strings  or  nodular  enlargements  appear  in  the 
course  of  the  great  veins,  with  consequent  eczema  and  ulceration. 
In  pregnant  woman,  eczema  is  common  in  other  regions,  on  the 
face,  the  hands,  the  forearms,  and  the  genitals ;  also  erythema, 
urticaria,  and  the  pustular  eruption  known  as  impetigo  herpetiformis. 

Parturition  and  lactation  entail  further  disfigurement  of  the  skin 
through  the  production  of  various  lesions,  such  as  cracks  and  fissures 
of  the  skin  of  the  breast,  dermatitis  due  to  venous  thrombosis  in  the 
lower  extremities,  scarring  of  the  breast  after  mastitis,  etc. 

In  the  description  of  the  sexual  life  of  woman  in  the  epoch  of  the 
menacme,  we  shall  consider  at  some  length  copulation  and  concep- 
tion, the  relations  of  fertility  and  sterility,  the  important  topic  of 
the  use  of  measures  for  the  prevention  of  pregnancy,  and  the  in- 
teresting subject  of  the  determination  of  sex;  on  the  other  hand, 
pregnancy,  parturition,  and  the  puerperal  state,  since  these  subjects 
are  specially  treated  in  the  ordinary  text-books  on  midwifery,  we 
shall  discuss  only  in  so  far  as  certain  relations  between  these  repro- 
ductive processes  and  the  organism  as  a  whole  and  its  functions, 
appear  to  us  especially  worthy  of  note. 

ANATOMICAL  CHANGES  IN  THE  FEMALE  GENITAL  ORGANS  IN  THE 
PERIOD  OF  THE  MENACME. 

In  the  fully-developed  woman  during  the  period  of  the  menacme, 
the  mons  Veneris  forms  a  rounded  elevation  which  consists  of  very 
14 


2io  THE  SEXUAL  LIFE  OF  WOMAN. 

dense  connective  tissue  containing  large  quantities  of  fat,  while  the 
integument  that  covers  it  is  usually  coated  with  a  thick  growth  of 
hair.  The  form  of  this  hairy  covering,  which  by  the  Roman  poets 
was  designated  Hebe,  by  the  Greeks  zunaikomustax  (translated  by 
Albrccht  Ditrer  as  Wcybsbart  —  woman's  beard),  by  Galen  termed 
ornamcntum  loci,  is  various,  and,  as  an  external  sexual  character,  it 
deserves  more  accurate  observation  than  it  has  hitherto  received  from 
anatomists. 

The  hairy  covering  of  the  female  genital  organs  is  in  adults,  and 
especially  in  brunettes,  very  abundant ;  above,  it  is  usually  sharply 
limited  by  a  transverse  line  across  the  top  of  the  mons  Veneris,  and 
it  extends  outwards  only  a  little  beyond  the  labia  majora,  whilst  be- 
low it  extends  only  to  about  the  middle  of  the  sides  of  the  perineum. 
According  to  Bcrgh,  however,  who  made  an  exact  study  of  this 
matter  in  2,200  women  of  ages  for  the  most  part  between  fourteen 
and  thirty  years,  in  some  cases  the  shape  of  the  patch  of  hair  (which 
is  in  such  instances  always  very  thick)  resembles  that  so  common  in 
the  male,  there  being  a  pointed  process,  usually  rather  narrow, 
extending  upward  toward  the  navel.  This  masculine  form  of  the 
pubic  hair  is  by  no  means  common  in  women;  according  to  Lom- 
broso  it  is  met  with  more  frequently  in  Italian  women  than  in  those 
belonging  to  other  European  nations.  In  most  women,  the  thick 
hairy  covering  of  the  mons  Veneris  is  sharply  limited  above  by  the 
curved  line  that  indicates  the  upper  margin  of  the  eminence,  whereas 
in  men  a  strip  of  hair  usually  passes  up  from  the  mons  pubis  to  the 
umbilicus.  Still,  exceptions  are  met  with.  Thus,  in  100  women, 
Schultze  found  five  in  whom  the  hairy  covering  extended  up  to  the 
navel.  Sometimes  other  variations  occur,  for  instance,  the  hair  may 
extend  laterally  into  the  groin,  occasionally  as  far  as  the  anterior 
superior  spine  of  the  ilium,  and  across  the  upper  part  of  the  front 
of  the  thigh,  not  infrequently  in  association  with  a  thick  growth  of 
hair  along  the  sides  of  the  perineum  as  far  as  the  anus.  Of  women 
with  the  hair  growing  in  this  fashion,  not  a  few  appeared  to  Bergh 
to  have  unusually  strong  sexual  passion. 

In  contradistinction  to  these  cases  in  which  the  development  of 
the  pubic  hair  is  thick  and  even  excessive,  we  meet  with  others  in 
which  it  is  very  scanty,  and  this  not  only  in  quite  young  individuals 
(at  an  age  from  15  to  18  years),  with  but  slight  development  of  the 
labia,  but  also  in  older  and  fully  developed  women  —  for  the  most 
part  blondes. 

The  growth  of  the  pubic  hair  is  thickest  and  strongest  near  the 
median  line,  whilst  laterally  the  hairy  covering  is  thinner  and 
weaker.  The  thickness  is  extremely  variable.  "  In  some  women  we 
find  a  flattened,  occasionally  frizzled,  turf-like  covering;  in  others, 


THE  SEXUAL  EPOCH  OF  THE  MENACME.  211 

a  dense,  elevated,  luxuriant  bush  of  hair  "  (Bergh).  The  length  of 
the  pubic  hair  is  variable,  but  as  a  rule  it  is  somewhat  shorter  in 
the  female  than  in  the  male.  Still,  cases  have  been  known  in  women 
in  which  it  reached  to  the  knees. 

The  colour  of  the  pubic  hair  commonly  resembles  that  of  the  hair 
of  the  head,  but  the  pubic  hair  is  usually  the  darker  of  the  two. 
Blondes  with  dark  or  black  eyebrows  have,  according  to  Bcrgh, 
usually  dark  or  black  pubic  hair.  The  pubic  hair  turns  grey  late  in 
life,  later  as  a  rule  than  the  hair  of  any  other  part,  a  fact  known  al- 
ready to  Aristotle;  it  is  rather  late  in  life  also  that  the  pubic  hair 
becomes  thin,  and  in  this  state  it  remains  almost  invariably  up  to 
an  advanced  age,  even  when  the  scalp  has  become  almost  or  quite 
bald. 

The  pubic  hair,  according  to  the  same  author,  is  seldom  straight, 
being  almost  always  curly,  frizzled,  or  more  or  less  rolled  up  into 
rings  or  spirals,  generally  forming  smaller  or  larger  locks.  Fairly 
often,  we  meet  with  curled  locks,  either  one  pair  or  two,  symmetri- 
cally disposed  on  either  side  of  the  depression  adjoining  the  prgepu- 
tium  clitoridis ;  these  usually  have  an  outward  direction.  Much 
more  rarely  we  find  similar  locks  symmetrically  attached  further  back 
on  the  labia. 

In  the  case  of  1,000  adult  women  examined  by  Eg  gel  with  regard 
to  the  colour  of  the  pubic  hair,  the  colour  of  the  eyes,  and  the  colour 
of  the  hair  of  the  head,  there  were  239  with  dark  eyes,  333  with  dark 
hair  on  the  head,  and  329  with  dark  pubic  hair;  contrariwise,  761 
had  light  eyes,  667  light  hair  on  the  head,  and  679  light  pubic  hair. 
Obviously, then, a  considerable  number  of  women  with  light-coloured 
eyes  must  have  had  dark  pubic  hair.  Rothe,  in  1,000  North  German 
women  examined  by  him,  found  the  pubic  hair  blonde,  but  a  rather 
dark  blonde,  in  a  large  majority  of  the  cases ;  in  red-haired  women, 
the  pubic  hair  was  in  all  cases  bright  red,  in  black-haired  women 
the  pubic  hair  was  black  in  two-thirds  only  of  the  cases,  in  nearly 
a  third  it  was  brown,  in  two  cases  dark  blonde;  in  Jewesses,  in  a 
large  majority  of  instances,  the  pubic  hair  is  brown.  The  arrange- 
ment of  the  pubic  hair  is  described  by  Rothc  as  very  variable. 
"  Sometimes  it  is  short  and  frizzly,  sometimes  a  luxuriant  bushy 
growth;  sometimes  the  hairs  are  scanty  and  thinly  set;  sometimes 
they  are  irregularly  distributed;  sometimes  we  see  only  a  narrow 
strip  of  long  hairs  down  the  middle  of  the  mons  Veneris,  which 
is  bare  at  the  sides.  In  some  the  lateral  boundaries  of  the  pubic 
hair  are  sharply  defined,  in  others  the  hairy  covering  spreads  beyond 
the  usual  limits." 

Among  the  ancient  Greeks  and  Romans,  it  was  customary  for 
women  to  remove  the  pubic  hair,  a  custom  even  now  observed  by  all 
oriental  races;  for  this  reason  in  ancient  art  the  nude  female  body 


212  THE  SEXUAL  LIFE  OF  WOMAN. 

is  depicted  without  pubic  hair.  According  to  Stratz,  in  the  Chansons 
dc  Bilitis  it  is  said  of  the  priestesses  of  Astarte :  "  They  never 
draw  their  hairs  out,  in  order  that  the  dark  triangle  of  the  goddess 
shall  represent  on  their  bodies  the  form  of  a  temple." 

The  physiological  purpose  of  the  pubic  hair  is  to  prevent  irritation 
of  the  genital  organs  by  the  sweat  that  would  otherwise  run  down 
upon  them,  and  to  protect  the  skin  from  direct  friction  during  the 
act  of  copulation. 

The  labia  majora  in  women  during  the  menacme  are  usually 
strongly  developed,  their  outer  surface  is  hairy ;  in  parous  women 
we  almost  invariably  observe  small  or  even  large  lacerations  of 
the  fraenulum  pudendi  or  fourchette,  in  front  of  the  posterior 
commissure  of  the  vulva.  On  the  inner  surface  also  of  the  labia 
majora,  the  general  characters  of  which  are  those  of  mucous  mem- 
brane rather  than  of  skin,  fine  hairs  are  also  to  be  found.  In  multi- 
parse,  and  even  in  women  who  have  frequently  had  sexual  inter- 
course, these  inner  surfaces  of  the  labia  majora  are  not  usually  any 
longer  in  mutual  contact,  so  that  the  rima  urogenitalis  or  vulval 
cleft  gapes  more  or  less.  In  well-nourished  women  who  have  led  the 
"  sheltered  life,"  the  dense  and  fat-containing  connective  tissue  of 
the  labia  majora  (continuous  with  and  similar  to  that  of  the  mons 
Veneris)  gives  these  structures  a  certain  firmness  and  elasticity,  and 
the  labia  minora  or  nymphae  do  not  project  beyond  them.  But  when 
the  genital  organs  are  not  well  preserved,  projection  of  the  nymphae 
occurs.  In  women  whose  genital  organs  are  beautifully  formed, 
the  nymphae  are  of  a  soft,  delicate  consistency,  and  their  mucous 
membrane  is  of  a  pink  color;  but  when  the  reproductive  organs 
have  been  subjected  to  excessive  stimulation,  the  nymphae  are  dry, 
hard,  brown  in  color,  and  they  project  from  the  vulval  cleft.  In 
women  of  the  Hottentot  and  Bosjesman  races,  the  nymphae  attain, 
as  is  well  known,  an  excessive  length,  forming  the  so-called  "  Hot- 
tentot-apron-;" and  in  certain  other  indigenous  races  of  Africa,  the 
enormous  size  of  these  organs  renders  resection  necessary. 

During  this  sexual  epoch,  in  women  with  strong  sexual  passion 
and  having  frequent  sexual  intercourse,  the  clitoris  is  largely  de- 
veloped, and  sometimes  the  dorsum  of  the  organ  protrudes  from 
between  the  anterior  extremities  of  the  labia  majora. 

The  vaginal  orifice  gapes  a  little,  so  that  the  irregular  carunculae 
myrtiformes  are  visible.  In  parous  women,  the  vaginal  orifice  is 
enlarged  in  such  a  manner  that  the  wall  of  the  vagina  passes  directly 
and  without  limitation  into  the  wall  of  the  vestibule,  and  the  ex- 
ternal orifice  (meatus)  of  the  uretha  is  situate  immediately  in 
front  of  the  anterior  vaginal  column,  and  thus  lies  within  the  vagi- 
nal orifice. 


THE  SEXUAL  EPOCH  OF  THE  MENACME.  213 

The  breasts  of  a  strong,  healthy  woman  who  has  attained  com- 
plete sexual  maturity  are  more  or  less  firm  in  consistency,  and 
considerable  in  size,  exceeding  now  Ovid's  demand  concerning  these 
organs,  ut  sit  quod  capiat  nostra  tegatque  manus.  The  normal 
hemispherical  form  and  the  somewhat  soft  texture  are  subject  to 
many  variations,  these  being  dependent  upon  race,  climate,  and  sexual 
activity  and  also  upon  the  kind  of  clothing  worn.  The  nipple  and 
its  encircling  areola  are  usually  of  a  brownish  colour ;  but  in  beautiful 
women  they  sometimes  retain  the  pink  colour  characteristic  of  these 
structures  in  the  virgin.  In  parous  women  who  have  suckled'  their 
children,  the  breasts  are  usually  pendent,  and  often  the  left  breast 
will  be  found  to  be  somewhat  larger  than  the  other;  generally  also 
in  such  women  the  nipples  are  longer  and  thicker  than  normal.  Not 
infrequently  the  nipples  are  withdrawn  into  a  furrow  of  the  skin, 
and  become  prominent  only  on  local  stimulation  or  as  a  result  of 
sexual  excitement.  Sometimes  in  the  region  of  the  areola,  especially 
in  brunettes,  we  see  a  circle  of  small  glands,  which  produce  eminences 
beneath  the  skin. 

It  is  easy  to  understand  that  the  breasts  of  such  women  in  gen- 
eral no  longer  have  the  virginal  form  of  small  hemispheres,  but 
have  matured  to  a  greater  fulness  and  size.  This,  however,  does 
not  diminish  their  beauty,  for  the  ideal  of  beauty  must  take  into 
account  the  natural  development  of  the  body.  Whereas  at  the  present 
time,  under  the  influence  of  the  modern  negation  or  at  any  rate 
undervaluation  of  maternity  as  the  goal  of  woman's  life,  it  is  the 
tendency  of  a  certain  school  of  art  to  misprize  the  influence  of  that 
state  on  the  form  of  the  breast,  and  to  esteem  the  "  flat  bosom,"  at 
an  earlier  day  under  the  influence  of  Rousseau's  Emile,  a  book  in 
which  mothers  are  strongly  urged  to  suckle  their  own  children,  the 
full  bosom  as  a  beauty  was  the  fashion  in  art. 

Only  a  perverted  taste  can  find  a  woman  beautiful  without  bosom 
—  without  "  that  golden  chalice,  from  which  men  quaff  love,  and 
children  life"  (Mantegazza}, —  an  angular,  flat  being,  without  a 
rounded  form.  Nothing  but  a  morbid  desire  for  equality  with  man 
can  induce  woman  herself  to  endeavor  to  conceal  also  the  external 
manifestation  of  her  sexual  characteristics,  and  by  her  clothing  to 
disguise,  like  a  nun,  the  sexual  curves  of  her  figure. 

Great  deposit  of  fat,  such  as  occurs  from  liberal  feeding  in  con- 
junction with  a  sedentary  mode  of  life,  or  as  a  result  of  several 
pregnancies,  destroys  the  beautiful  form  of  the  breasts,  which  attain 
an  immoderate  size,  thus  disturbing  the  grace  and  symmetry  of  the 
feminine  figure,  a  fact  recognized  already  by  the  Romans.  Hyrtl 
condemns,  from  the  point  of  view  of  anatomical  beauty,  the  nude 
female  figures  in  the  pictures  of  Rubens,  remarking  that  "  the  god- 


214  THE  SEXUAL  LIFE  OF  WOMAN. 

classes  and  angels  of  this  painter  are  as  luxuriant  in  their  develop- 
ment as  a  Flemish  dairy-maid ;"  and  the  buxom  "  goat's-udder 
breast "  prized  by  the  Arabs  does  not  represent  any  nobler  ideal  of 
beauty.  Sometimes  these  excessively  large  and  fat  breasts  hang 
down  in  a  conical  form,  or,  as  more  or  less  flattened  hemispheres, 
reach  right  down  over  the  gastric  region;  moreover,  the  interspace 
between  the  two  breasts  seems  to  disappear,  and  they  touch  or  rub 
against  one  another. 

According  to  Ploss  and  Bartels,  the  various  forms  of  breast  oc- 
curring in  different  races  may  be  classified  as  follows:  A.  Accord- 
ing to  size :  i,  very  large ;  2,  large ;  3,  medium ;  4,  small.  B.  Accord- 
ing to  consistency  and  firmness  :  I,  high  ;  2,  semi-pendent ;  3,  pendent. 
C.  According  to  shape:  I,  shell-shaped  (disc-shaped)  ;  2,  hemispheri- 
cal ;  3,  conical.  The  nipples  also,  according  to  these  authors,  ex- 
hibit variations  dependent  upon  race,  being  in  some  cases  small  and 
flat,  like  a  little  knob,  in  some  cases  large  and  conical  in  shape,  with 
a  broad  base  and  a  rounded  extremity,  and  in  some  cases  large  and 
cylindrical,  having  almost  the  shape  of  a  finger-joint.  The  areola, 
finally,  is  in  some  women  quite  pale  in  color,  in  some  dark  pink,  in 
some  brown  and  even  almost  black  from  excess  of  pigment. 

The  uterus  of  a  woman  who  has  attained  complete  sexual  maturity, 
has  undergone  such  alterations  in  its  proportions  that  the  cervix 
and  the  body  are  of  almost  the  same  length.  The  constriction,  visible 
externally,  indicating  the  separation  between  these  two  segments. 
of  the  organ,  is  depressed  somewhat  toward  the  external  os.  In 
sexually  active  women,  a  widening  and  an  increased  curvature  of 
the  region  of  the  fundus  occur,  the  uterine  extremities  of  the  Fallo- 
pian tubes  becoming  more  widely  separated ;  at  the  same  time  the 
posterior  wall  becomes  more  and  more  convex.  The  more  fre- 
quently the  uterus  has  functioned  as  a  reproductive  organ,  the  more 
strongly  marked  -is  the  convexity  of  the  body  of  that  organ.  The 
relative  lengths  of  the  corporal  and  cervical  portions  of  the  uterine 
cavity  are  now  the  reverse  of  those  that  obtain  in  the  uterus  of  the 
child;  the  transverse  and  antero-posterior  diameters  have  greatly 
increased.  Transverse  diameter  at  the  fundus ;  virgin,  4  centimetres 
(1.575"),  multipara,  5.5-6.5  centimetres  (2.165-2.559"):  sagittal 
(antero-posterior)  diameter;  virgin,  2  centimetres  (0.787")  ;  multi- 
para,  3-3.5  centimetres  (1.181-1.378").  (Chrobak  and  von  Rost- 
horn. ) 

During  the  menacme,  in  consequence  of  the  act  of  reproduction, 
the  uterus  undergoes  important  changes  in  form.  In  a  nulliparous 
married  woman,  the  uterus  differs  little  from  that  of  a  virgin ;  the 
cavity  is  somewhat  more  extensive,  the  convexity  of  the  outer  sur- 
face a  little  greater,  there  is  some  increase  in  width  in  the  neighbor- 


THE  SEXUAL  EPOCH  OF  THE  MENACME.  215 

hood  of  the  fundus,  the  plicae  palmatae  (arbor  vita;  utcrinum}  are 
confined  to  the  cervical  canal ;  further,  under  the  influence  of  copula- 
tion the  appearance  of  the  vagina  changes,  it  becomes  larger,  and 
its  walls  become  smoother,  sometimes  quite  smooth,  from  the  dis- 
appearance of  the  rugae  of  the  mucous  membrane  and  especially  of 
those  attached  to  the  posterior  vaginal  column.  Much  more  ex- 
tensive are  the  alterations  in  the  uterus  of  a  multipara.  According  to 
Toldt,  "  the  parts  of  the  cavity  representing  the  cornua,  which  are 
pointed  on  either  side  as  they  pass  toward  the  Fallopian  tubes,  be- 
come completely  included  in  the  lower  undivided  portion  of  the 
cavity,  this  change  being  effected  chiefly  by  means  of  the  increasing 
outward  curvature  of  the  walls,  so  that  the  cavity  comes  to  assume  an 
amygdaloid  form ;  the  cervical  canal  is  also  enlarged,  especially  the 
lower  part,  where  also  the  plicae  palmatae  (arbor  vita:  titcrinnm)  be- 
comes less  distinct;  the  vaginal  portion  of  the  cervix  is  shortened, 
the  os  uteri  externum  gapes,  the  lips  of  the  cervix  are  tumid,  nearly 
equal  in  length,  and  usually  beset  with  scarred  depressions."  In 
nulliparae,  the  vaginal  portion  of  the  cervix  is,  as  in  a  virgin,  of  a 
rather  tough  consistency,  smooth  on  the  surface,  while  the  external 
os  is  small,  like  a  dimple,  or  transversely  oval ;  the  color  of  the 
vaginal  portion  of  the  cervix  is  identical  with  that  of  the  vaginal 
mucous  membrane  in  general.  Through  frequent  copulation,  how- 
ever, the  form  of  the  vaginal  portion  of  the  cervix  is  so  far  altered 
inasmuch  as  it  is  more  freely  supplied  with  blood,  and,  therefore, 
changes  slightly,  in  consistency.  In  multiparae,  in  consequence  of 
lacerations  of  the  cervix,  the  os  uteri  externum  changes  to  a  wide 
transverse  fissure  with  tumid  margins,  justifying  the  old  designa- 
tion of  this  orifice  as  os  tinea,  carp's  mouth.  A  large  size  of  the 
external  and  internal  os,  moderate  enlargement  of  the  cavity,  round- 
ing of  the  upper  angles  adjacent  to  the  uterine  orifices  of  the  Fallo- 
pian tubes,  increased  convexity  of  the  walls,  and  partial  or  complete 
effacement  of  the  plicae  palmatae  (arbor  vita:  utcrinum],  are  the 
characteristics  of  the  uterus  of  a  multipara  (Chrobak  and  von  Rost- 
Jiorn).  According  to  Hennig,  the  vaginal  portion  of  the  cervix  is 
longest  in  women  who  have  undergone  defloration,  and  in  nulliparae ; 
widest  in  prostitutes ;  narrowest  in  childless  wives ;  thickest  in  young 
widows.  This  author  gives  the  following  measurements  of  the  ex- 
ternal os,  showing  its  variations  in  accordance  with  age  and  sexual 
activity : 

In  childhood,  transversely  oval 0.46  —  0.56  cm.  (0.18  —  0.22") 

In  the  virgin,  rounded 0.20  —  0.50  cm.  (0.08  —  0.20") 

In  prostitutes,    transversely,  oval 0.60 — 2.50  cm.  (0.24  —  0.98") 

In  sterile  married  women,  round 0.16  cm.  (0.06") 

In  parous  married  women,  transverse  fis- 
sure     l.iocm.  (0.43") 

After  the  menopause o.Si  cm.  (0.32") 


216  THE  SEXUAL  LIFE  OF  WOMAN. 

In  the  fully-developed  woman,  the  ovaries  undergo  changes  in  size, 
shape,  and  consistency,  these  changes  being  dependent  upon  the 
age,  the  sexual  functional  activity,  and  the  constitutional  predisposi- 
tions of  the  individual.  The  average  length  of  the  ovary  is  3-4  centi- 
metres (1.18-1.58");  the  average  width,  2-3  centimetres  (0.79- 
1.18")  ;  and  the  average  thickness  i  centimetre  (0.39").  The  sur- 
face of  this  organ  gradually  assumes  a  ragged  appearance,  from  the 
scarred  depressions  caused  by  the  great  number  of  successive  men- 
struations (ovulations) — sometimes  the  appearance  produced  re- 
sembles that  of  a  mulberry. 

In  the  vagina  at  this  sexual  epoch,  the  surface  of  the  anterior  and 
posterior  vaginal  walls  is  rendered  uneven  and  rugose  by  well-devel- 
oped vaginal  columns  (column®  rngarum), which  feel  almost  as  hard 
as  cartilage,  and  project  considerably  above  the  general  level  of  the 
wall ;  the  transverse  ridges  (ruga1)  run  horizontally  outward  from  the 
columns.  By  frequent  copulation,  the  rugae  are  partially  effaced,  and 
the  columns  themselves  become  flatter  and  softer;  still,  except  in 
cases  in  which  the  genital  functions  are  exercised  to  great  excess, 
the  vagina  remains  tense  and  rugose  until  after  several  children  have 
been  born,  when  it  becomes  soft,  flaccid,  and  smooth.  Even  in  women 
who  have  been  accustomed  to  frequent  intercourse,  the  narrowest 
portion  of  the  vagina  is  still  the  orifice  and  the  part  of  the  passage 
lying  immediately  within  the  orifice,  which  can  be  constricted  by  the 
levator  ani  muscle ;  childbirth,  however,  brings  about  great  and 
permanent  distension  of  these  parts  also.  The  widest  and  most  dis- 
tensible portion  of  the  vagina  is  the  uppermost  segment,  the  region 
of  the  fornices. 

A  special  significance  must  be  attached' to  the  glands  of  the  cervix 
uteri,  which,  according  to  my  own  observations,  have  the  function 
of  providing  a  secretion  that  increases  the  mobility  of  the  spermato- 
zoa, and  this  enables  them  more  readily  to  find  their  way  into  the 
uterus.  I  have  endeavored,  by  a  series  of  histological  observations,  to 
determine  the  properties  of  these  glands  and  the  changes  they  un- 
dergo in  the  different  phases  of  sexual  life.  The  most  important 
results  of  these  researches  may  be  stated  as  follows.  These  glands, 
which  are  lined  with  columnar  ciliated  epithelium,  are  but  slightly 
developed  before  puberty,  being  then  simple  excavations ;  at  the 
time  of  the  menarche,  they  become  tubular ;  later,  during  the  me- 
nacme,  they  become  long,  dendriform,  blind-ending  glands,  which 
during  menstruation  and  under  the  influence  of  sexual  excitement, 
furnish  a  secretion,  variable  in  quantity,  and  in  quality  distinguished 
especially  by  its  alkaline  reaction ;  further,  in  connection  with  a 
number  of  pathological  disorders  of  the  female  genital  organs,  these 
glands  undergo  various  changes  both  in  their  anatomical  structure 
and  in  their  secretory  activity.  At  the  time  of  the  menopause  and 


THE  SEXUAL  EPOCH  OF  THE  MENACME. 


217 


after  the  climacteric  age,  these  glands,  which  have  hitherto  con- 
sisted of  branched  tubules,  tend   to  undergo  cystic  degeneration, 


FIG.  52. —  Sagittal  section  through  the 
cervix  uteri  of  a  woman  26  years  of  age. 
dendriform  branched  glands. 


FIG.  53. — Cervix  of  a  woman 
72  years  of  age,  with  glands 
that  have  undergone  cystic 
degeneration. 


leading  to  the  formation  of  the  vesicles  known  as  ovula  Nabothi. 
After  the  climacteric,  the  existence  of  these  cysts  may  be  regarded 
as  a  normal  occurrence ;  and,  sometimes  arranged  in  grape-like 
clusters,  they  often  project  so  as  to  occupy  the  greater  part  of  the 
lumen  of  the  cervical  canal. 


FIG.  54. —  Sagittal  section  through  the  cervix  uteri  of  a  woman  65  years 
of  age.     The  glands  have  undergone  cystic  degeneration. 

Diseases  of  the  uterine  mucous  membrane  during  the  period  of 
sexual  maturity  often  induce  various  pathological  changes  in  these 
cervical  glands.  In  consequence  of  obstruction  of  their  excretory 


2i8  THE  SEXUAL  LIFE  OF  WOMAN. 

ducts,  they  may  undergo  cystic  degeneration,  forming  follicles  filled 
with  mucus  and  epithelium,  or  cavities  containing  blood,  which  pass 
through  the  substance  of  the  cervix  in  every  direction ;  or  tlu-y 
may  give  rise  to  the  formation  of  slowly-growing  glandular  polypi 
and  other  glandular  new  formations  —  changes  the  general  result 
of  all  of  which  is  to  interfere  with  the  secretory  function  of  the 
glands. 

PATHOLOGY  OF  THE  MENACME. 

The  full  evolution  of  the  sexual  life  brings  in  its  train  many 
dangers  to  a  woman's  life.  This  appears  at  first  sight  from  a  com- 
parison of  the  mortality  of  married  women  during  the  period  of 
greatest  sexual  activity  with  that  of  single  women  of  similar  age. 
Between  the  ages  of  20  and  25  years,  the  mortality  of  married 
women  is  in  all  races  higher  than  that  of  unmarried  women ;  and 
the  same  is  true  between  the  ages  of  25  and  30  years,  except  in 
France,  in  which  country  from  artificial  causes  maternity  ceases 
at  a  very  early  age.  In  Prussia,  in  the  year  1880,  of  every  10,000 
married  women,  between  the  ages  named,  21  died,  of  every  10,000 
unmarried  women,  only  2.  In  Holland,  Belgium,  and  Bavaria,  this 
excess  in  the  mortality  of  married  women  continues  up  to  the  age 
of  40  years ;  whilst  in  Prussia,  from  the  age  of  30  upward,  the 
mortality  of  married  women  and  unmarried  is  practically  the  same. 
In  many  countries,  the  mortality  of  married  women  at  many  ages 
exceeds  even  that  of  unmarried  men. 

This  greater  comparative  mortality  of  married  women  is  ascribed 
by  Hegar  to  the  satisfaction  of  the  sexual  impulse,  and  this  authority 
believes  that  the  dangers  attendant  on  this  function  would  be  mani- 
fested yet  more  clearly  if  the  contrast  were  made, not  between  married 
women  and  single,  but  between  those  habituated  to  sexual  indulgence 
and  those  who  are  continent.  We,  however,  are  of  opinion,  that 
the  satisfaction  of  the  sexual  impulse  is  only  harmful  to  this  extent, 
that  it  exposes  women  to  the  consequences  of  venereal  infection, 
and  also  to  the  risk  of  numerous  puerperal  and  other  diseases  of 
the  genital  organs.  This  is  proved  also  by  the  statistical  results  of 
the  investigations  concerning  mortality  during  pregnancy,  parturi- 
tion, and  the  puerperium.  According  tc  Hcgar,  adding  deaths  re- 
sulting from  premature  delivery  to  deaths  resulting  from  delivery 
at  full  term,  we  find  the  mortality  of  childbirth  in  Germany  to  be 
about  0.6  per  cent. 

Whilst  Bertillon  and  Simpson  believe  that  the  lower  mortality 
of  married  women  above  forty  years  of  age  as  compared  with  un- 
married women  at  the  same  period  of  life  is  dependent  upon  the 
advantage  to  the  former  of  the  fulfilment  of  sexual  functions,  Hegar, 
on  the  contrary,  gives  another  explanation.  He  writes :  "At  the 


THE  SEXUAL  EPOCH  OF  THE  MENACME.  219 

age  of  40,  the  less  powerful  married  women  have  already  been 
weeded  out.  At  first,  owing  to  the  selection  exercised  by  marriage, 
the  quality  of  the  unmarried  women  was  inferior  to  that  of  the 
married  women ;  the  former,  however,  have  not  been  exposed  to 
the  dangers  attendant  on  the  reproductive  process,  and  so  have 
passed  through  the  time  during  which  the  body  possesses  the  greatest 
elasticity ;  but  in  the  years  in  which  a  decline  in  the  vital  powers 
naturally  sets  in,  the  originally  inferior  quality  of  the  unmarried 
women  is  manifested  by  a  comparatively  higher  mortality.  Also  we 
have  to  take  into  account  among  the  unmarried,  the  consequences  of 
extra-marital  sexual  intercourse  and  of  prostitution,  and  further  the 
lack  of  a  family,  of  the  support  furnished  by  husband  and  children." 

In  addition  to  the  far-reaching  disturbances  of  health  dependent 
on  sexual  activity  at  this  period  of  life,  there  are  the  minor  domestic 
troubles  by  which  woman  is  depressed  and  by  which  her  powers  are 
exhausted.  The  influence  of  these  latter  is  admirably  described  by 
G.  von  Amyntor:  "  How  many  millions  of  brave  house-wives  boil 
and  scrub  away  their  vital  energy,  their  rosy  cheeks,  their  merry 
dimples,  in  the  performance  of  their  household  duties,  until  they 
become  wrinkled,  worn-out,  dried-up  mummies.  The  ever-renewed 
question,  '  what  must  be  cooked  for  dinner  to-day,'  the  perpetually 
recurring  necessity  for  sco'uring  and  sweeping  and  dusting  and 
washing-up  —  these  are  the  continual  dropping  which  slowly  but 
surely  wears  away  soul  and  body.  *  *  *  On  the  flaming  altar 
on  which  the  sauce-pan  simmers,  youth  and  simplicity,  beauty  and 
good  temper,  are  offered  up ;  and  who  can  recognize  in  the  old, 
hollow-eyed  cook  whose  back  is  bent  with  toil  and  trouble,  the  once 
blooming,  energetic,  chastely  coquettish  bride  adorned  with  her 
myrtle  crown  ?  " 

A  great  number  of  the  diseases  of  the  female  genital  organs  oc- 
curring at  the  epoch  of  the  menacme  need  only  a  passing  mention. 
Even  coitus,  in  cases  in  which  there  is  great  disproportion  in  size 
between  the  penis  and  the  vaginal  orifice,  or  when  the  organ  is  very 
rapidly  introduced  or  the  act  is  very  roughly  performed,  may  lead 
to  injury  to  the  vulva  or  the  vagina,  a  fact  to  which  a  very  large 
number  of  recorded  cases  bears  witness. 

During  the  acme  of  the  sexual  life  of  woman,  disturbances  of  the 
menstrual  function  are  also  frequent.  Menstruation  may  cease  in 
consequence  of  intercurrent  diseases  or  constitutional  anomalies; 
amenorrhcea  may  occur  during  the  convalescence  from  acute  dis- 
eases, in  obese  women,  in  those  suffering  from  tuberculosis,  diabetes, 
alcoholism,  or  psychoses.  On  the  other  hand,  severe  menorrhagia 
or  atypical  metrorrhagia  may  occur,  the  bleeding  either  being  due 
to  diseases  of  the  uterus,  such  as  endometritis,  retroflexion  of  the 


220  THE  SEXUAL  LIFE  OF  WOMAN. 

uterus,  or  uterine  myomata,  or  resulting  from  infectious  diseases, 
disease  of  the  heart  or  kidney,  or  from  general  disturbance  of  the 
health  by  chill  or  over-exertion.  Or,  again,  dysmenorrhoea  may  arise, 
either  as  a  symptom  of  some  local  uterine  disease  or  in  consequence 
of  external  noxious  influences  or  weakness  of  the  nervous  system. 

During  the  life-epoch  of  the  menacme,  moreover,  disturbances  of 
the  nutrition  of  the  uterus  are  of  common  occurrence,  as,  for  ex- 
ample, hyperplastic  processes  in  the  mucous  membrane  of  the  cervical 
canal  and  of  the  cavity  of  the  body  of  the  uterus.  Common  also 
during  the  menacme  is  chronic  oophoritis,  which  may  be  due  to  mal- 
regulation  of  marital  intercourse  (especially  to  coitus  too  soon  after 
childbirth),  to  carelessness  during  menstruation  (dancing,  skating,  or 
mountaineering),  to  incomplete  coitus  (congressus  intcrruptus},  and 
not  infrequently,  to  gonococcal  infection ;  or,  finally,  the  oophoritis 
may  occur  soon  after  the  puerperium  in  association  with  subinvolu- 
tion  of  the  uterus. 

Next  we  may  mention  inflammatory  diseases  of  the  Fallopian 
tubes.  In  the  etiology  of  these  diseases  in  latter-day  marriage,  a 
dominant  role  must  be  assigned  to  the  gonococcus ;  but  they  also 
arise  in  many  cases  from  nutritive  disturbances,  infection  (other 
than  gonorrhceal ),  and  indiscretions  during  menstruation.  Pelvic 
peritonitis  owns  similar  causation. 

In  this  phase  of  women's  life,  the  commonest  new  growths  of  the 
uterus,  myomata,  also  develop,  most  commonly  between  the  ages 
of  thirty-six  and  forty-five,  and  they  occur  in  strikingly  larger  pro- 
portion in  unmarried  women ;  it  is  between  the  same  ages  also  that 
cysto-adenomata  of  the  ovaries  are  of  commonest  occurrence. 

Sexual  intercourse  gives  frequent  opportunities  for  the  introduc- 
tion of  infective  germs  into  the  vagina,  and  for  the  origination  of 
inflammatory  affections  of  the  mucous  membrane  (colpitis),  the 
intensity  of  which  depends  upon  the  species,  the  quantity,  and  the 
virulence  of  the  germs  in  question,  on  the  one  hand,  and  upon  the 
local  and  constitutional  predisposition  of  the  infected  person,  upon 
the  other.  Especially  grave  in  its  consequences  is  gonorrhoeal  in- 
fection transmitted  by  the  male,  for  this  virus  gives  rise  to  a  great 
variety  of  pathological  processes  in  the  female  genital  organs.  In 
the  act  of  defloration,  considerable  injuries  are  sometimes  produced, 
and  these  readily  supply  a  breach  for  the  invasion  of  infective  organ- 
ims.  The  condition  of  passive  hyperaemia  that  occurs  in  the  genital 
organs  during  pregnancy  also  provides  a  favorable  soil  for  their 
growth. 

Gonorrhoeal  infection  of  young  married  women  is  so  frequent  and 
so  serious  an  occurrence  in  the  sexual  life  of  woman,  that  it  requires 
special  consideration.  The  cases  in  which  the  man  entering  upon 


THE  SEXUAL  EPOCH  OF  THE  MENACME.  221 

marriage  is  so  unscrupulous  and  so  brutal  as  to  deflower  his  young 
wife  and  to  continue  copulating  with  her,  while  suffering  himself 
from  a  quite  recent  and  active  gonorrhoea,  are  on  the  whole  rare. 
More  common  is  it  for  the  bridegroom  to  believe  himself  completely 
cured  of  his  previous  claps,  and  he  is  declared  cured  by  his  phy- 
sician. The  disease  is,  however,  latent  merely,  the  gonorrhoea  has 
become  chronic,  the  discharge  is  so  slight  that  it  is  overlooked ;  but 
by  the  stimulation  of  the  frequent  acts  of  coition  usual  in  the  early 
days  of  marriage,  the  disease  is  lighted  up  afresh,  the  gonococci 
multiply  quickly  and  intensely,  the  young  wife  is  infected,  and 
suffers  from  an  acute  gonorrhoea,  which  may  often  escape  observa- 
tion for  a  considerable  period. 

In  a  gonorrhoeal  marriage,  one  in  which  both  husband  and  wife 
have  gonococci  in  their  genital  organs,  very  diverse  phenomena  may 
be  observed  and  very  various  conditions  may  result.  On  this  sub- 
ject M.  Runge  writes :  "  If  the  husband's  gonorrhoea  is  not  cured, 
fresh,  virulent  cocci  are  repeatedly  transmitted  to  the  wife,  in  whom, 
therefore,  the  disease  often  gets  worse  by  distinct  stages.  If  the 
wife  undergoes  treatment,  the  effect  in  these  circumstances  will 
naturally  be  nil,  since  the  husband  is  always  supplying  fresh  infec- 
tion. On  the  other  hand,  the  wife  on  her  side  returns  the  gonococci 
to  her  husband,  and  in  this  way  his  gonorrhoea  may  undergo  aggrava- 
tion. If  the  husband  is  compelled,  by  illness,  for  instance,  or  by 
absence,  to  abstain  for  a  long  period  from  intercourse  with  his  wife, 
the  latter's  gonorrhoea  may,  in  favorable  circumstances,  undergo 
alleviation  and  cure.  It  may  happen,  however,  that  in  the  husband, 
in  consequence  of  sexual  rest,  the  gonorrhoea  becomes  latent,  and 
even  entirely  disappears,  whilst  the  wife  still  suffers  from  infection. 
If  now,  after  long  abstinence,  the  husband  has  renewed  intercourse 
with  his  wife,  he  may  be  reinfected,  and  suffer  from  an  acute  attack 
of  gonorrhoea,  though  this  is  due  to  the  descendants  of  the  very 
gonococci  that  he  himself  sometime  before  conveyed  to  the  genital 
organs  of  his  wife  — he  reinfects  himself,  as  people  say.  Such 
cases  have  given  rise  to  suspicions  of  unchastity  on  the  part  of  the 
wife,  when  the  husband  is  in  actual  fact  enjoying  his  own  work  in 
a  new  edition.  A  further  possibility  is  that  both  husband  and  wife 
have  become  habituated  to  their  own  gonococcal  interchange ;  that 
is  to  say,  the  organisms  produce  no  notable  effect  in  either.  But  if 
the  wife  in  such  a  condition  receives  the  embraces  of  a  lover,  the 
latter  may  be  infected  with  an  acute  gonorrhoea  —  a  fact  that  has 
long  been  known." 

The  principal  role  in  the  etiology  of  the  diseases  of  the  female 
genital  organs  must  be  assigned  to  pregnancy  and  childbirth.  Anae- 
mic women  readily  suffer  during  pregnancy  from  a  further  decrease 


222  THE  SEXUAL  LIFE  OF  WOMAN. 

in  the  corpuscular  richness  of  the  blood ;  those  affected  with  valvular 
incompetence  find  their  troubles  much  aggravated  by  pregnancy ; 
where  the  kidneys  are  in  an  irritable  condition,  pregnancy  not  infre- 
quently results  in  the  onset  of  nephritis ,  those  with  disordered  di- 
gestion often  suffer  from  increased  disturbance  of  the  functions 
of  the  stomach  and  the  intestinal  tract ;  those  with  gall-stones  are 
apt  to  suffer  from  exceptionally  severe  attacks  of  biliary  colic,  and 
acute  yellow  atrophy  of  the  liver  is  especially  apt  to  occur  during 
pregnancy.  In  women  in  whom,  dilatations  of  the  veins  already  exist, 
very  great  increase  of  the  enlargement  is  apt  to  occur  during  preg- 
nancy; and  in  the  same  circumstances,  trifling  teleangiectases  in- 
crease to  extensive  angiomata.  Enlargements  of  the  thyroid  body 
undergo  rapid  increase  during  pregnancy,  so  that  they  may  attain 
threatening  proportions.  In  women  in  whom  the  abdominal  walls 
are  flaccid,  the  viscera  may  protrude  during  pregnancy  through  the 
enlarged  lacunae,  giving  rise  to  herniae.  The  great  relaxation  of  the 
peritoneal  and  other  ligamentous  attachments  of  the  great  abdominal 
glands,  occurring  during  pregnancy  and  the  puerperium  results  in 
displacements  of  these  organs;  hepatoptosis  (migrating  or  movable 
liver),  lienoptosis  (splenoptosis  or  wandering  spleen),  nephroptosis 
(ren  mobile,  floating  or  movable  kidney),  and  other  varieties  of  entero- 
ptosis  (splanchoptosis,  visceroptosis,  or  Glenard's  disease).  During 
pregnancy,  previously  sound  teeth  are  apt  to  become  carious,  and  al- 
ready existing  caries  rapidly  advances.  New  growths  of  various  kinds 
originate  at  this  period,  those  previously  present  exhibit  rapid  increase ; 
and  relapse  after  operations  for  the  extirpation  of  malignant  tumors  is 
especially  apt  to  occur.  Even  the  bones  are  unfavorably  influenced. 
A  weakened  nervous  system  is  subject  to  a  storm  of  changing 
nervous  troubles,  in  some  cases  so  severe  as  to  lead  to  the  outbreak 
of  actual  psychoses;  while  mental  disorder  already  present  tends, 
as  a  rule,  to  be  seriously  aggravated  during  pregnancy.  In  the  eyes, 
serious  disorders  may  occur,  such  as  retinitis,  and  atrophy  of  the 
choroid  with  complete  amaurosis.  As  regards  the  hearing,  tinnitus 
aurium  is  not  uncommon,  and  sometimes  complete  deafness  occurs. 
Numerous  diseases  of  the  skin  are  apt  to  occur  during  pregnancy ; 
in  addition  to  the  well-known  pigmentation  of  the  face,  the  areola 
mammae,  and  other  parts,  we  may  have  herpes,  eczema,  or  pruritus. 
The  serious  aggravation  which  pregnancy  is  liable  to  induce  in 
many  disorders  previously  existent,  is  well  known,  and  this  exacer- 
bation provides  in  some  cases  an  indication  for  the  induction  of  ar- 
tificial abortion.  This  necessity  may  arise  in  severe  cases  of  renal, 
cardiac,  pulmonary,  or  hepatic  disease,  in  progressive  anaemia,  severe 
osteomalacia  haemophilia,  and  many  other  acute  and  chronic  patho- 
logical states,  since,  in  exceptional  cases,  as  pregnancy  advances,  the 


THE  SEXUAL  EPOCH  OF  THE  MENACME.  223 

symptoms  of  any  one  of  these  diseases  may  become  so  threatening, 
that  the  patient's  life  is  either  in  immediate  danger  or  is  almost 
certain  to  be  in  danger  within  a  very  short  space  of  time  —  this  may 
occur,  for  instance,  in  diabetes,  struma  (goitre),  or  certain  nervous 
diseases,  such  as  chorea,  polyneuritis  (multiple  neuritis),  or  mental 
disorders.  Undoubtedly,  in  this  connection,  as  W.  A.  Freund  in- 
sists, it  is  not  the  actual  nature  of  the  disease  that  is  of  decisive 
importance,  but  rather  its  intensity,  and  its  influence  on  the  health  of 
the  pregnant  women ;  these  circumstances,  considered  'in  relation  to 
the  resisting  powers  of  the  patient,  must  be  determinative  in  the  adop- 
tion of  measures  for  terminating  the  pregnancy.  An  indication  for 
the  induction  of  artificial  abortion  is  generally  furnished  also  by  un- 
controllable vomiting  dependent  on  pregnancy  and  endangering  the 
life  of  the  patient ;  irreducible  incarceration  of  a  retroflexed  gravid 
uterus  in  the  pouch  of  Douglas^  or  of  a  gravid  uterus  in  a  hernia,  or 
irreducible  prolapse  of  a  gravid  uterus  will  also  necessitate  abortion. 

W.  A.  Freund  gives  an  example  of  a  common  pathological  state, 
usually  quite  free  from  danger,  but  now  and  again,  when  as- 
sociated with  pregnancy,  seriously  endangering  life  and  rendering  the 
induction  of  artificial  abortion  absolutely  necessary  —  this  is  acute 
struma  v&sculosa  —  (vascular  enlargement  of  the  thyroid  body), 
which  may  during  the  first  three  months  of  pregnancy  exhibit  such 
rapid  growth  as  to  lead  to  severe  orthopnoea  and  cyanosis  and  so  to 
imperil  the  patient's  life. 

In  cases  in  which  laryngeal  tuberculosis  exists  as  a  complication  of 
pulmonary  tuberculosis,  the  former  disease  sometimes  progresses 
so  rapidly  in  the  course  of  pregnancy  that  sudden  death  from  oedema 
of  the  glottis  is  by  no  means  rare.  Freund,  therefore,  sees  in  this 
complication  an  absolute  indication  for  the  artificial  termination  of 
the  pregnancy. 

In  cases  of  previously  well-compensated  vulvular  lesions  of  the 
heart,  disturbances  of  compensation  not  infrequently  occur  as  a  re- 
sult of  pregnancy ;  whilst  in  cases  in  which  cyanosis,  dyspnoea,  al- 
buminuria,  and  dropsy  existed  even  before  pregnancy,  the  latter 
condition  is  likely  to  result  in  an  aggravation  of  these  symptoms  to 
a  degree  that  imperils  life. 

Parturition,  to  an  even  greater  extent  than  pregnancy,  may  in- 
duce serious  injuries  to  the  female  organism.  Thus,  during  parturi- 
tion, lacerations  of  the  vagina  are  frequent,  with  consequent  scar- 
formation  and  stenosis ;  lacerations  of  the  perineum  are  also  com- 
mon, causing  great  inconvenience,  and  when  complete,  leading  to 
incontinence  of  faeces  with  all  its  unpleasant  consequences.  Great 
is  the  danger  arising  from  septic  puerperal  inflammations,  such  as 
pelvic  peritonitis  (perimetritis)  ;  serious  are  the  results  of  puerperal 
vesico-vaginal  and  recto-vaginal  fistula?. 


224  THE  SEXUAL  LIFE  OF  WOMAN. 

A  large  part  in  the  local  pathology  of  the  female  genital  organs  is 
played  by  the  various  displacements  of  the  uterus,  either  arising  in 
consequence  of  inflammatory  processes  in  their  ligaments,  or  de- 
pendent upon  relaxation  of  these  ligaments  from  subinvolution  of 
the  internal  generative  organs,  either  following  delivery  at  full 
term  or  following  abortion. 

The  injury  which  women  alike  of  the  well-to-do  and  of  the  labor- 
ing classes,  suffer  in  consequence  of  numerous  and  frequently  re- 
peated pregnancies,  is  minutely  described  by  Hegar.  "  We  can,"  he 
writes,  "  calculate  the  danger  to  life  to  which  such  an  unfortunate 
woman  is  exposed  by  the  act  of  reproduction.  If  we  assume  the 
ordinary  mortality  of  women  in  childbed  to  be  6  per  mille,  then, 
in  a  woman  who  within  15  years  has  been  delivered  16  times 
(whether  prematurely  or  at  full  term,  the  danger  will  be  16  times 
as  great  as  that  of  a  single  delivery,  and  the  mortality  will  be 
6X16  =  96  per  mille;  that  is  to  say,  of  1,000  women  who  have  all 
been  pregnant  that  number  of  times,  96  will  die  —  nearly  I  in  10. 
Moreover,  in  this  calculation  the  increased  danger  consequent  upon 
the  unusually  rapid  sequence  of  the  deliveries  has  not  been  taken 
into  consideration.  And,  again,  only  the  immediate  results  of  the 
deliveries  have  been  taken  into  the  account.  Not  infrequently  women 
succumb  at  a  later  date  to  illnesses  acquired  in  childbed ;  whilst 
others,  in  consequence  of  repeated  pregnancies,  have  their  powers  of 
resistance  so  greatly  diminished,  that  they  are  unequal  to  the  contest 
with  incidental  diseases.  In  any  case,  a  woman  who  has  experienced 
numerous  and  rapidly  successive  pregnancies,  has  sustained  dam- 
ages which  will  endure  for  the  rest  of  her  life.  Her  tissues  have 
lost  their  elasticity,  the  abdominal  walls  are  flaccid,  the  abdomen  is 
prominent,  the  abdominal  viscera  are  displaced,  the  vessels  dilated, 
the  reproductive  organs  in  a  state  of  subinvolution,  and  are  the  seat 
of  structural  alterations.  The  greatest  dangers  arise  in  cases  in 
which  the  pregnancies  are  consequences  that  have  to  be  paid  for 
illicit  love,  since  in  such  cases  syphilitic  and  gonorrhceal  infection  are 
exceptionally  common.  These  complications,  indeed,  are  not  ex- 
cluded in  the  case  of  married  women,  since  marital  infidelities  occur, 
and,  again,  a  premarital  but  not  completely  cured  venereal  illness  may 
bear  fruit  in  marriage,  the  latter  occurrence  being  almost  always  at- 
tributable to  the  husband.  Syphilitic  or  gonorrhceal  infection  may 
also  arise  in  some  other  way  than  by  copulation,  and  to  this  women 
are  more  exposed  than  men,  owing  to  the  greater  size  of  the  genital 
passage  in  the  former." 

Very  numerous  are  the  disorders  of  the  nervous  system  referable 
to  the  sexual  functional  activity  of  woman  during  this  epoch  of  her 
sexual  life. 


THE  SEXUAL  EPOCH  OF  THE  MENACME.  225 

Frcund,  in  his  description  of  a  neurasthenic  symptom-complex 
to  which  he  gives  the  name  of  angst-neurosis,™  maintains  that  the 
cause  of  these  attacks  of  anxiety36  is  very  frequently  to  be  found  in 
a  number  of  injurious  influences  in  the  sphere  of  the  sexual  life. 
In  women,  these  anxiety-neuroses  occur : 

a)  As  virginal  anxiety,  or  anxiety  of  adolescents.  Frcund  has 
observed  a  number  of  unequivocal  instances  showing  that  a  first 
encounter  with  the  sexual  problem,  a  rather  sudden  utiveiling  of 
what  has  hitherto  been  concealed,  as,  for  instance,  the  sight  of  some 
sexual  act,  or  something  read  or  heard  in  conversation,  may,  in  a 
girl  at  the  time  of  puberty,  give  rise  to  an  anxiety-neurosis,  which 
is  in  a  very  typical  manner  combined  with  hysteria. 

fc)  As  anxiety  of  the  newly  married.  Young  wives  who  have 
been  without  sexual  feeling  in  their  first  experience  of  intercourse 
are  not  infrequently  attacked  by  an  anxiety-neurosis,  which,  how- 
ever, disappears  as  soon  as  the  sexual  feeling  becomes  normal. 
Since,  indeed,  the  majority  of  young  women  who  lack  sexual  feel- 
ing in  their  first  experience  of  sexual  intercourse  remain  neverthe- 
less quite  healthy,  it  is  evident  that  some  other  cause  must  cooperate 
in  arousing  the  anxiety-neurosis. 

c)  As  anxiety  in  married  women  whose  husbands  suffer  from 
ejaculatio  praco.r  or  from  great  diminution  of  sexual  potency,  or 

d)  Whose  husbands  practice  coitus  interruptus  or  coitus  reser- 
vatus.     Cases  in  these  two  classes  are  closely  associated,  since  it  is 
easy  to  ascertain,  from  the  analysis  of  a  sufficiently  large  number 
of  cases,  that  the  really  important  question  is,  whether  during  coitus 
the  wife  obtains  or  fails  to  obtain  sexual  satisfaction.     In  the  latter  - 
event,  the  condition  requisite  to  arouse  the  anxiety-neurosis  is  sup- 
plied. 

e)  As  anxiety  in  widows  and  in  voluntary  abstinents,  not  infre- 
quently in  typical  combination  with  impulsive  ideas. 

/)  As  anxiety  in  the  climacteric  period,  during  the  final  flare-up 
of  sexual  passion. 

Numerous  anomalies  of  the  genital  organs  which  gave  rise  in  the 
virgin  to  no  trouble  whatever  display  their  influence  during  the 
menacme  by  unfavorably  affecting  the  nervous  system.  Thus,  in 
cases  of  malformations  of  the  external  organs  of  generation,  slight 
atresia  of  the  vagina,  a  rudimentary  condition  of  the  vagina,  a  rigid 
hymen,  or  local  changes  in  the  vagina,  it  is  only  when  sexual  inter- 
course begins  that  neuroses  or  hysteroneurasthenic  troubles  ensue. 

36  The  German  word  Angst,  here  translated  anxiety,  is  used  in  various 
senses,  ranging  from  anxiety  lo  anguish,  according  as  the  mental  element  or 
the  element  of  pure  feeling  predominates  in  the  conception.  In  the  case  of 
the  angst-neurosis.  however,  a  condition  of  mental  uneasiness  would  appear 
to  be  connoted,  and  therefore  anxiety  is  the  best  rendering. —  Tr. 

15 


226  THE  SEXUAL  LIFE  OF  WOMAN. 


< 


So  also  at  times  nervous  diseases  which,  though  the  disposition  to 
them  was  present,  were  latent  in  the  girl,  such  as  epilepsy  and  various 
mental  disorders,  first  become  apparent  in  consequence  of  sexual 
intercourse. 

The  mechanical  irritation  of  the  nerves  of  the  pelvis  that  occurs 
in  sexual  intercourse  may,  even  in  women  whose  reproductive  organs 
are  healthy,  arouse  sensations  of  weight,  pressure,  and  bearing-down, 
various  painful  sensations  in  the  sacral  region,  over  the  coccyx,  in 
the  buttocks,  or  in  the  upper  part  of  the  thighs,  and  also  "  lumbar 
enlargement  symptoms,"  37  viz.,  weakness  of  the  lower  extremities, 
abnormal  sensations  of  fatigue  in  the  lower  extremities  and  the 
back,  sometimes  also  disorders  of  micturition  and  defsecation. 

Throughout  the  manifold  diseases  of  women  in  or  connected  with 
the  reproductive  system  during  the  age  of  sexual  maturity,  associated 
mental  processes  take  place,  which  powerfully  affect  the  nervous 
system.  Such  processes  are,  melancholy  and  anxious  thoughts  con- 
cerning the  possible  influence  of  the  illness  on  the  happiness  of  mar- 
ried life,  concerning  childlessness,  or  concerning  loss  of  a  husband's 
sexual  esteem,  or  again,  fear  that  the  affection  will  become  can- 
cerous, fear  of  some  necessary  operative  procedure,  or  vexation  in 
consequence  of  the  limitation  of  her  usefulness  as  housewife,  wife, 
and  mother.  Thus  in  women  suffering  from  sexual  affections,  a 
state  of  general  neurasthenia,  or  some  neurasthenic  functional  dis- 
turbance of  other  organs,  very  commonly  arises. 

The  knowledge  that  she  is  suffering  from  an  affection  of  the 
genital  organs,  makes  a  deep  and  lasting  impression  on  the  mind 
of  a  woman  who  takes  a  serious  view  of  her  duties  as  a  wife,  and 
whose  thoughts  and  feelings  are  concentrated  in  the  sexual  sphere. 
The  result  is,  that  minor  troubles  are  regarded  through  the  magnify- 
ing lens  of  anxiety,  and  the  general  sensibility  is  increased.  This 
hyperaesthesia  is  not  confined  to  the  affected  region,  but  manifests 
itself  in  various  other  parts  of  the  body  by  numerous  phenomena  of 
a  reflex  character.  In  the  first  place  must  be  mentioned  severe 
headaches,  sacrache,  sensations  of  pressure  in  the  abdomen,  car- 
diac troubles,  palpitation,  stomach-ache,  nausea  and  retching  and 
disorders  of  appetite  and  digestion.  Capacity  for  work  and  the 
enjoyment  of  life  are  destroyed  by  these  disorders. 

We  have  further  to  take  into  account  the  numerous  conditions 
liable  to  disturb  the  mind  at  this  period  of  life.  In  childless  women, 
we  have  the  subject  of  their  sterility,  the  continued  yearning  to  be 
blessed  with  children,  the  eager  search  for  a  remedy,  and  not  rarely 
in  these  cases  the  conflict  between  the  reproductive  impulse  and  the 
ethical  principle  of  conjugal  fidelity.  In  fruitful  mothers,  on  the 

37  German,   Lcndcnmarksymptome. 


THE  SEXUAL  EPOCH  OF  THE  MENACME.  227 

other  hand,  we  have  the  anxiety  lest,  by  too  frequent  childbearing 
their  beauty  should  be  impaired  and  the  livelihood  of  the  family  en- 
dangered ;  these  considerations  leading  in  many  cases  to  the  practice 
of  coitus  reservatus,  with  its  deleterious  physical  and  moral  conse- 
quences. In  the  middle  and  working  classes,  we  have  the  strain 
of  the  endeavor  to  be  a  helpful  companion  to  the  husband  and  at 
the  same  time  to  assist  in  the  support  and  the  education  of  the 
children.  Last  but  not  least,  we  have  the  potent  influence  of  local 
therapeutic  measures,  and  the  fear  of  operative  procedures,  both 
of  which  have  a  most  agitating  effect  on  a  woman's  mind.  In  truth, 
the  menacme  is  a  period  full  of  stormy  excitations  and  powerful 
revolutions. 

In  addition  to  its  influence  on  the  genital  organs  themselves,  the 
sexual  life  of  woman  during  the  period  of  the  menacme  manifests 
its  powers  for  evil  especially  in  relation  to  the  digestive  functions, 
and  to  the  functions  of  the  heart  and  the  nervous  system. 

When  we  compare  the  various  consequences  which  may  be  in- 
duced in  the  principal  organic  systems  as  a  result  of  functional 
disturbances  and  organic  diseases  of  the  farnale  genital  organs,  we 
find  that  in  respect  of  the  frequency  of  their  occurrence  the  diseases 
of  the  nervous  system  occupy  the  first  rank ;  next  in  frequency  come 
the  disorders  of  the  digestive  organs  that  arise  in  sympathetic  as- 
sociation with  diseases  of  the  female  reproductive  organs ;  whilst  the 
third  rank  in  respect  of  frequency  and  importance  is  occupied  by  the 
cardiac  disorders  that  arise  in  connection  with  changes  in  the  female 
organs  of  generation,  and  take  the  form  either  of  disturbances  of 
the  heart's  functions  or  structural  changes  in  the  heart's  muscle. 

Dyspepsia  Uterina. 

Although  it  has  long  been  a  familiar  observation  that  pregnant 
women  and  women  suffering  from  diseases  of  the  reproductive  or- 
gans suffered  from  various  dyspeptic  troubles,  I  was  myself  the 
first  (in  the  Berliner  Klinische  Wocheiischrift,  1883)  to  bring  to- 
gether, and  to  describe  under  the  name  of  dyspepsia  uterina,  a  pe- 
culiar group  of  dyspeptic  conditions  which  are  dependent  upon  dis- 
eases of  the  female  reproductive  organs.  I  dismissed  from  considera- 
tion organic  diseases  of  the  stomach  and  intestine  dependent  upon 
anatomical  changes  in  these  organs,  even  though  these  also  might  owe 
a  similar  etiology,  and  described  only  the  more  frequent  dyspepsias 
occurring  without  organic  change  in  the  digestive  apparatus,  the  ori- 
•gin  of  which  is  to  be  explained  by  the  fact  that  certain  structural 
changes  and  displacements  of  the  uterus  (to  be  discussed  later) 
arouse  centripetal  impulses,  and  that  these  exercise  a  reflex  influence 
on  digestive  activity. 


228  THE  SEXUAL  LIFE  OF  WOMAN. 

This  influence,  according  to  my  observations,  affects  the  secretory 
and  muscular  apparatus  and  also  the  nervous  elements  of  the  di- 
gestive tract,  and  I  regard  the  following  conditions  as  characteristic 
of  uterine  dyspepsia,  though  they  do  not  necessarily  all  occur  simul- 
taneously :  changes  in  the  gastric  secretion,  excitement  of  the  vomit- 
ing centre,  an  inhibitory  influence  on  intestinal  peristalsis,  and 
hypenesthesia  of  the  stomach. 

The  symptoms  of  uterine  dyspepsia  may  vary  greatly  in  intensity, 
but  not  infrequently  become  so  severe  as  to  disturb  very  seriously 
the  general  health  of  the  woman  so  affected.  They  may  be  enu- 
merated as  follows :  The  appetite  in  uterine  dyspepsia  is  variable, 
but  is  generally  good;  the  tongue  is  not  usually  coated  to  any 
great  extent,  nor  does  the  mucous  membrane  of  the  mouth  com- 
monly exhibit  any  notable  change ;  pain  in  the  epigastrium  is  com- 
mon after  meals,  with  acid  eructations  and  heartburn  (pyrosis)  5s8 
sometimes  there  is  violent  vomiting,  occurring  after  every  meal,  or 
in  the  morning  on  an  empty  stomach ;  in  addition,  constipation  is 
an  almost  constant  symptom,  associated  with  excessive  development: 
of  gases  in  the  intestinal  canal.  The  pain  is  usually  dull  in  char- 
acter, and  somewhat  relieved  by  pressure,  but  it  may  be  severe, 
and  lancinating,  and  may  shoot  along  the  intercostal  spaces.  The: 
accumulation  of  flatus  within  the  abdomen  gives  rise  to  various ; 
painful  sensations,  distension,  a  sense  of  fulness;  and-its  expulsion: 
is  attended  with  notable  relief. 

As  regards  the  composition  of  the  gastric  secretion,  an  increase1 
of  acidity  is  sometimes  noticed.  Gastric  digestion  is  retarded;  ex-- 
perimental  evacuation  of  the  stomach,  after  a  simple  test  meal  (beef- 
steak and  roll)  showed  that  small  quantities  of  undigested  remnants 
were  to  be  found  in  the  stomach  as  long  as  seven  or  eight  hours 
afterwards.  The  frequent  eructations  evacuate  flatus,  or  else  a 
watery  fluid  with  an  acid  reaction  (pyrosis  or  ivater-brash  —  see 
note  38).  By  the  act  of  vomiting,  larger  or  smaller  masses  of 
the  food  that  has  been  taken  are  evacuated;  in  the  vomit,  sarcinse 
in  large  numbers  may  frequently  be  detected  by  the  microscope. 
Constipation  is  present  in  nearly  all  cases  of  uterine  dyspepsia ;  and 
even  in  cases  in  which  attacks  of  diarrhoea  occur  from  time  to  time, 
careful  examination  will  show  that  these  are  generally  transient, 
being  sequelae  of  constipation  due  to  the  irritation  caused  by  the 
accumulated  masses.  In  one  case  of  long-standing  uterine  dyspepsia, 
I  observed,  in  the  absence  of  any  gastric  dilatation,  the  well-known 

38 German,  saures  Aufstossen  und  Sodbrennen;  for  the  latter  noun  heart-- 
burn would  appear  to  be  the  most  precise  English  equivalent,  since  the  term 
pyrosis  is  sometimes  employed  to  denote  the  acid  eructation  (or  neater-brash) 
and  sometimes  the  accompanying  sensation  at  the  pit  of  the  stomach  —  heart- 
burn or  cardialgia.  Etymologically,  of  course,  the  latter  sense  of  pyrosis  is 
correct  (Greek,  rcop,  fire). —  TK. 


THE  SEXUAL  EPOCH  OF  THE  MENACME.  229 

phenomenon  of  "peristaltic  restlessness  of  the  stomach"  (tormina 
ventriculi  nervosa),  in  which  the  peristaltic  activity  of  the  stomach 
is  greatly  exalted,  and  becomes  visible  to  the  naked  eye  in  the  form 
of  large  and  powerful  undulations  in  the  gastric  region,  moving  from 
left  to  right. 

With  these  symptoms  affecting  the  digestive  organs  are  associated 
variable  nervous  manifestations  in  different  organs,  such  as  neuralgia 
of  various  nerves,  palpitation  of  the  heart,  vertigo,  headache,  and 
nervous  asthma.  The  general  nutrition  of  the  body  often  suffers 
considerably  in  cases  of  long-enduring  uterine  dyspepsia ;  excessive 
emaciation  and  general  marasmus  may  ensue;  we  see  also  mental 
depression,  melancholia,  an  irritable  disposition,  and  disinclination 
for  every  kind  of  work. 

Very  important,  but  very  difficult,  is  the  differential  diagnosis 
between  uterine  dyspepsia,  on  the  one  hand,  and,  on  the  other, 
chronic  gastric  catarrh,  chronic  ulcer  of  the  stomach,  nervous  dys- 
pepsia, and  sometimes  even  carcinoma  of  the  stomach. 

As  regards  the  distinction  from  chronic  gastric  catarrh,  in  this 
latter  disease  loss  of  appetite  and  changes  in  the  oral  mucous  mem- 
brane are  prominent  symptoms  ;  the  vomit  also  usually  contains  much 
mucus.  More  difficult  is  the  differential  diagnosis  of  chronic  ulcer 
of  the  stomach,  in  cases  in  which  anaemic  subjects  complain  of 
anomalies  of  menstruation,  associated  with  dyspeptic  troubles  and 
cardialgia.  In  severe  cases  of  uterine  dyspepsia,  the  distinction  from 
carcinoma  of  the  stomach  may  be  very  difficult  —  at  any  rate  in 
cases  in  which  no  examination  of  the  genital  organs  has  been  made. 
Obstinate  dyspeptic  troubles,  resisting  all  curative  measures  (unless 
indeed  these  are  directed  to  the  relief  of  the  local  disorder  of  the 
reproductive  organs),  progressive  anaemia,  great  emaciation,  and 
pains  localized  in  the  stomach,  are  all  conditions  common  to  both 
of  these  maladies.  The  absence  of  a  tumor  of  the  stomach,  care- 
ful examination  of  the  vomit,  and  examination  of  the  genital  organs, 
will  lead  to  a  correct  diagnosis  if  the  case  is  one  of  uterine  dyspepsia. 
A  superficial  investigation  is  exceedingly  likely  to  result  in  a  case 
of  uterine  dyspepsia  being  regarded  as  one  of  nervous  dyspepsia 
(von  Leube}  ;  none  the  less,  even  though  a  very  close  resemblance 
exists  between  the  symptoms  of  the  two  diseases,  to  differentiate 
them  is  a  matter  of  importance.  In  nervous  dyspepsia,  the  act  of 
digestion  influences  the  nervous  system  in  such  a  manner  that,  even 
when  the  chemical  processes  are  normal,  the  organism  as  a  whole 
is  sympathetically  affected  by  a  reflex  from  the  stimulation  of  the 
nerves  of  the  stomach,  and  in  return  reacts  on  the  mechanical  process 
of  digestion  in  a  more  or  less  violent  manner.  In  uterine  dyspepsia, 
however,  the  relationship  that  obtains  is  exactly  the  reverse  of  this, 


230  THE  SEXUAL  LIFE  OF  WOMAN. 

inasmuch  as  the  gastric  activity  is  influenced  by  the  nervous  system, 
by  reflex  impulses  originating  in  the  morbid  processes  in  the  repro- 
ductive organs ;  moreover,  in  this  form  of  dyspepsia,  in  direct  con  - 
trast  with  nervous  dyspepsia,  the  chemistry  of  digestion  is  often 
disordered,  and,  in  addition,  the  process  is  not  completed  within  the 
normal  period. 

Oftentimes,  the  diagnosis  of  uterine  dyspepsia  can  be  made  with 
certainty  only  ex  jurantibits.3*  For  this  disorder  cannot  be  cured 
unless  the  disease  of  the  reproductive  organs  on  which  it  depends  is 
first  relieved ;  and,  conversely,  local  measures  for  the  relief  of  uterine 
disease,  will  often  at  once  remove  all  the  dyspeptic  troubles  from 
which  the  patient  suffers. 

My  own  experience  has  led  me  to  conclude  that  it  is  certain  dis- 
tinct local  mechanical  stimuli  affecting  the  female  genital  organs 
which,  acting  for  a  long  period  on  the  sensory  nerves  of  the  uterus 
or  its  annexa,  induce  by  reflex  action  the  before-mentioned  digestive 
disturbances.  Diseases  of  the  vulva  and  the  vagina,  catarrhal  in- 
flammation, colpitis  and  leucorrhoea,  and  prolapse  of  the  vagina, 
do  not  by  themselves  lead  to  the  occurrence  of  uterine  dyspepsia ; 
nor  do  inflammations  of  the  uterine  mucous  membrane,  such  as  en- 
dometritis  (unless  associated  with  parenchymatous  changes  of  the 
whole  uterus),  chronic  catarrh  of  the  mucous  membrane,  erosion 
and  ulceration  of  the  cervix  to  an  inconsiderable  extent,  or  mod€rate 
perimetritic  and  parametritic  exudations.  On  the  other  hand,  uterine 
dyspepsia  frequently  ensues  in  cases  of  uterine  displacements, 
flexions,  or  versions,  or  in  cases  of  structural  changes  of  the  uterus 
accompanied  by  enlargement  of  the  organ,  chronic  metritis,  myo- 
ma'ta,  especially  when  intramural  (interstitial),  displacement  of  the 
Fallopian  tubes  and  the  ovaries,  chronic  oophoritis,  extensive  in- 
flammatory exudations,  resulting  from  pelvic  peritonitis,  and  lead- 
ing to  dislocation,  "  compression  ''  or  distortion  of  the  uterus  and  its 
annexa,  deep  follicular  or  carcinomatous  ulceration  of  the  cervix,  or, 
finally,  ovarian  tumors.  As  the  commontest  condition  giving  rise  to 
dyspeptic  disturbances  of  the  kind  under  consideration,  retroflexion 
of  an  enlarged  uterus  must  be  mentioned. 

Under  the  head  of  uterine  dyspepsia,  we  may  also  classify  dyspep- 
tic disturbances  occurring  at  the  time  of  puberty  or  of  the  meno- 
pause, and  in  association  with  certain  amenorrhceic  and  dysmenor- 
rhoeic  conditions,  and,  in  addition,  the  vomiting  of  pregnant  women. 

The  vomiting  of  pregnant  women,  which  must  be  regarded  as  a 
reflex  disturbance  of  the  stomach,  occurs,  with  especial  severity  in 
first  pregnancies,  in  the  early  months  of  pregnancy,  with  such  regu- 
larity that  it  is  regarded  as  one  of  the  most  typical  signs  of  preg- 

39  By  consideration  of  the  results  of  treatment. 


THE  SEXUAL  EPOCH  OF  THE  MENACME,  231 

nancy.  Thus,  in  177  pregnant  women,  Horwitz  observed  vomiting 
in  147  (83  of  whom  were  primiparae,  and  64  multipart),  and  in 
29  only  was  this  symptom  wanting.  In  this  series  of  cases,  it  most 
commonly  made  its  appearance  between  the  tenth  and  eleventh  week 
of  the  pregnancy.  The  vomiting  of  pregnant  women  occurs  most 
commonly  early  in  the  morning,  immediately  after  rising  (morning 
sickness),  but  also  at  other  times  of  the  day;  it  usually  takes  place 
easily,  without  any  great  distress,  and  after  it  is  over  the  patient 
feels  quite  comfortable.  It  rarely  continues  later  than  the  fourth 
month  of  pregnancy. 

Very  serious  in  its  effect  on  the  general  state  of  nutrition  is  the 
uncontrollable  vomiting  that  sometimes  occurs  in  pregnant  women 
(hypcremesis  gr  avid  or  urn) ,  lasting  throughout  the  whole  term  of 
pregnancy.  It  must  be  regarded  as  an  exaggeration  of  the  physio- 
logical vomiting  of  pregnant  women,  in  patients  whose  nervous 
equilibrium  is  profoundly  disturbed ;  but  equally  with  the  ordinary 
"  morning  sickness "  is  it  dependent  on  the  reflex  stimulation 
of  the  nerves  of  the  stomach  exercised  by  the  growing  uterus.  One 
source  of  such  stimulation  may  be  found  in  the  stretching  of  the 
peritoneal  investment  of  the  uterus  which  results  from  the  enlarge- 
ment of  that  organ ;  another,  in  certain  displacements  of  the  uterus ; 
but  in  addition  to  these  local  anomalies,  we  must  assume  the  exist- 
ence of  a  peculiar  predisposition  on  the  part  of  the  nervous  system, 
in  virtue  of  which  reflex  irritability  is  increased,  while  the  power  of 
reflex  inhibition  is  diminished.  . 

The  prognosis  and  treatment  of  uterine  dyspepsia  depend  chiefly 
upon  the  nature  of  the  diseases  of  the  female  genital  organs  that 
have  given  rise  to  the  disturbances  of  digestion,  and  this  pathological 
relationship  demands  above  all  a  careful  investigation.  The  follow- 
ing instance  from  my  own  case-book  may  be  regarded  as  typical 
of  cases  of  this  class.  Mrs.  N.,  aged  25,  married  6  years,  barren, 
complains  of  severe  dyspeptic  trouble.  Appetite  fairly  good,  but 
after  every  meal  severe  gastralgia  occurred,  with  heartburn  and  acid 
eructations,  and  very  often  the  food  was  rejected ;  there  was  also 
obstinate  constipation,  and  great  distress  from  the  accumulation  of 
flatus  in  the  intestinal  canal.  No  blood  was  ever  seen  in  the  vomit. 
The  patient  was  much  emaciated,  and  was  greatly  depressed  in 
spirits.  Neither  in  the  lungs  nor  in  the  digestive  organs  had  any 
of  the  physicians  under  whose  care  the  lady  had  been  for  the  last 
four  years  found  any  abnormal  change  to  account  for  the  stormy 
manifestations.  Now,  at  length,  the  gynecological  examination, 
which  had  hitherto  been  neglected,  was  undertaken.  The  uterus 
was  found  to  be  strongly  retroflexed  and  enlarged.  Rectification  of 
the  position  of  this  organ  was  immediately  followed  by  the  disappear- 
ance of  all  the  stomach  troubles ;  the  vomiting  ceased,  some  months 


232  THE  SEXUAL  LIFE  OF  WOMAN. 

later  the  woman  became  pregnant,  and  pregnancy  and  parturition 
were  quite  normal;  since  then  there  has  been  no  return  of  the 
dyspepsia. 

Since  the  appearance  of  my  work  on  dyspepsia  uterina,  numerous 
observations  have  in  recent  years  been  published,  proving  even  more 
clearly  the  causal  dependence  of  disturbances  of  the  gastric  function 
upon  diseases  of  the  female  genital  apparatus. 

Lamy,  for"  example,  has  made  an  elaborate  study  of  one  of  the 
above-mentioned  symptoms  of  uterine  dyspepsia,  namely,  excite- 
ment of  the  vomiting  centre.  His  conclusions  are  '  as  follows : 
Among  the  general  symptoms  of  diseases  of  the  uterus,  dyspepsia, 
in  all  its  forms  and  in  all  degrees  of  intensity,  occupies  the  first  rank 
in  respect  of  frequency  of  occurrence.  Among  the  accompaniments 
of  these  reflex  processes,  uterine  vomiting  must  be  mentioned.  It 
seldom  occurs  as  the  sole  symptom  of  disorder  of  the  digestive 
organs ;  but  when  it  does  occur  alone,  it  is  of  great  importance  that 
the  cause  of  the  affection  should  not  be  misunderstood.  Diseases 
of  the  uterus  and  periuterine  affections  are  the  conditions  that  most 
commonly  give  rise  to  this  trouble,  but  in  a  certain  number  of 
cases  it  is  due  to  physiological  changes  in  the  female  genital  organs. 
Such  changes  are  those  associated  with  the  functional  activity  of 
the  reproductive  apparatus  at  the  time  of  puberty,  during  menstrua- 
tion, in  connection  with  coitus,  during  pregnancy,  and  at  the  change 
of  life,  the  menopause.  The  vomiting  of  pregnant  women  is  of 
the  same  nature,  and  confirms  our  belief  in  the  uterine  origin  and 
pathogenesis  of  vomiting  at  other  times  than  during  pregnancy.  The 
diagnosis  of  the  true  cause  of  uterine  vomiting  cannot  be  made 
from  the  nature  of  the  latter,  but  only  from  a  knowledge  of  the  con- 
ditions in  which  it  occurs,  just  as  with  other  uterine  reflexes,  such 
as  neuralgia  or  cough.  The  vomit  may  consist  merely  of  the  food 
last  taken,  or  it  may  contain  bile,  without  the  presence  of  this  latter 
constituent  indicating  the  existence  of  any  disease  of  the  liver.  The 
treatment  of  this  disorder,  which  indeed  does  not  threaten  life,  but 
does  seriously  impair  the  general  state  of  nutrition,  must  be  local, 
directed  against  the  disease  of  the  genital  organs :  Thus,  in  one 
case  of  this  nature,  a  cure  was  effected  by  oophorectomy. 

The  majority  of  the  women  in  whom  Lamy  observed  this  symptom 
of  uterine  dyspepsia  were  chloro-anaemic  individuals  with  an  ir- 
ritable nervous  system,  town-dwellers,  young  girls  in  whom  fre- 
quent evening  parties  and  dances,  ill-chosen  diet,  and  a  gen- 
erally unsuitable  mode  of  life,  had  led  to  the  development  of  a 
"  virginal  metritis."  The  signs  of  the  disturbance  of  the  gastric 
functions  were  in  the  first  place  a  retardation  of  gastric  digestion 
while  the  appetite  remained  good.  Moreover,  the  stomach  was 


THE  SEXUAL  EPOCH  OF  THE  MENACME.  233 

often  distended  with  flatus,  and  this  caused  frequent  gaseous  eructa- 
tions; there  was  also  epigastric  pain,  which  made  it  difficult  for 
the  patient  to  bear  the  pressure  of  the  clothing,  and  sometimes 
great  pain  was  aroused  by  the  slightest  contact.  The  attacks  of 
vomiting,  which  occurred  in  a  characteristic  manner  with  periodical 
intervals  of  freedom,  were  usually  preceded  for  a  longer  or  shorter 
period  by  dyspeptic  symptoms.  The  vomiting  itself,  if  it  occurred 
immediately  after  a  meal,  was  not  accompanied  by  nausea,  a  feeling 
of  faintness,  or  cold  sweats,  but  rather  resembled  a  kind  of  pain- 
less regurgitation ;  but  when  the  vomiting  did  not  occur  till  some 
hours  after  food  had  been  taken,  it  was  painful,  and  the  vomit  was, 
then  green-tinted  owing  to  the  admixture  of  bile. 

The  gastric  troubles  that  occur  during  menstruation  are  regarded 
by  P.  Miiller  as  a  further  indication  of  the  intimate  connection  be- 
tween the  genital  organs  and  the  digestive  tract  In  women  who 
suffer  from  hysterical  manifestations,  gastric  disturbances,  eardialgia, 
and  nervous  dyspepsia,  are  very  frequently  associated  with  men- 
struation. These  gastric  symptoms  generally  make  their  appearance 
a  few  days  before  menstruation  is  due,  and  disappear  as  soon  as  the 
flow  is  established.  In  other  forins,  again,  the  digestive  troubles 
set  in  with  the  appearance  of  the  flow,  to  disappear  during  the  later 
course  of  menstruation ;  and  in  yet  other  cases  the  gastric  disturb- 
ance begins  even  later,  and  ceases  only  when  the  flow  comes  to  an 
end.  These  symptoms  may  occur  in  women  in  whom  the  genital 
organs  are  perfectly  healthy  and  in  whom  menstruation  runs  a 
regular  course.  More  severe  symptoms  may,  however,  appear  if 
menstruation  is  disturbed  for  any  reason,  or  if  it  is  suppressed, 
Not  rarely  such  women,  when  they  become  pregnant,  suffer,  espe- 
cially during  the  early  months,  from  dyspeptic  symptoms;  but 
similar  dyspepsia  may  occur  in  pregnant  women  who  have  previously 
been  quite  healthy. 

To  the  same  category  belong  the  cases  formerly  described  by  von 
Leyden  under  the  designation  of  neuralgia  and  hyperaesthesia  of 
the  stomach,  which  he  observed  in  young  girls  as  a  sequel  of  men- 
strual disturbances,  and  more  particularly  of  suppressio  mensium. 
In  these  circumstances,  the  sensibility  of  the  stomach  may  become 
:so  extreme  that  every  time  food  is  taken  the  patient  suffers  from 
such  severe  pains,  or  from  so  distressing  a  sense  of  anxiety  and 
oppression,  that  she  comes  to  eat  less  and  less,  and  an  extreme  de- 
gree of  emaciation  and  marasmus  results.  In  one  such  case,  con- 
genital atrophy  of  the  uterus  was  discovered  on  gynecological  ex- 
.-amination. 

According  to  R.  Arndt,  it  is  especially  in  chloro-neurotic  individ- 
uals that  the  stimuli  proceeding  from  morbid  conditions  of  the 
reproductive  organs  frequently  induce,  by  reflex  action,  all  kinds 


234  THE  SEXUAL  LIFE  OF  WOMAN. 

of  disturbances  of  the  alimentary  tract,  such  as  constipation  and 
flatulence,  gastric  uneasiness  and  loss  of  appetite,  weakness  of  di- 
gestion, cardialgia,  and  stricture  of  the  cesophagus.  Even  simple 
menstruation  suffices  to  give  numerous  proofs  of  this  fact,  but  still 
more  do  such  consequences  arise  from  serious  diseases  of  the  re- 
productive organs,  such  as  changes  in  form,  displacements,  and  in- 
flammatory states,  and  also,  on  the  other  hand,  more  or  less  pro- 
nounced hypoplasia. 

G.  Broun  has  published  three  cases  illustrating  the  connection 
between  neurosis  of  the  stomach  and  uterine  disorders.  In  the  first 
of  these  cases,  severe  digestive  disturbances  occurred  after  every 
meal,  with  occasionally  violent  vomiting,  in  a  woman,  aged  twenty- 
five  years.  No  changes  were  found  in  the  stomach  or  other  digestive 
organs,  and  the  symptoms  obstinately  resisted  all  direct  treatment. 
Gynecological  examination  showed  extreme  mobility  of  the  uterus, 
and  for  the  relief  of  this  a  suitable  pessary  was  introduced.  The 
vomiting  thereupon  immediately  ceased,  all  the  other  digestive 
troubles  passed  completely  away,  and  the  general  state  of  nutrition, 
which  had  before  been  so  much  impaired  as  to  necessitate  the  use 
of  nutrient  enemata  of  meat-solution,  now  became  normal.  The 
second  case  was  that  of  a  woman  aged  thirty,  who,  since  her  last 
confinement  two  years  before,  had  continually  suffered  from  dis- 
agreeable gastric  sensations  and  from  vomiting,  which  latter  had 
proved  quite  uncontrolable.  Gynecological  examination  disclosed 
extensive  laceration  of  the  cervix  with  ectropium  of  the  mucous 
membrane.  An  operation  was  performed  for  the  relief  of  this  con- 
dition, and  the  vomiting  of  two  years  standing  was  also  thereby 
cured.  In  the  third  case,  that  of  a  woman  twenty-eight  years  old, 
vomiting  began  three  months  after  her  confinement,  and  recurred 
whenever  the  patient  left  the  recumbent  posture,  in  which  latter 
she  felt  quite  well.  On  local  examination,  the  uterus  was  found 
to  be  prolapsed,  the  vaginal  portion  of  the  cervix  moderately  en- 
larged and  just  within  the  vaginal  orifice.  Amputation  of  the  vag- 
inal portion  of  the  cervix  cured  the  vomiting  and  completely  re- 
stored the  patient's  health. 

The  frequency  of  gastric  affections  in  cases  of  retroflexion  of  the 
uterus  is  insisted  on  by  Panccki.  In  eight  instances  he  found  neu- 
roses of  the  stomach  consequent  upon  such  retroflexion,  and  in  all 
cases  a  cure  immediately  followed  rectification  of  the  position  of 
the  uterus.  He  urges  that  if  after  the  reposition  of  the  retroflexed 
uterus  the  gastric  troubles  should  still  persist,  a  careful  local  exa- 
amination  of  the  stomach  is  indispensable. 

Eiscnhart,  in  a  woman  forty-two  years  of  age,  corrected  a  mobile 
retroflexion  of  the  uterus,  and  thereupon  very  severe  gastric  symp- 
toms of  several  months'  duration  soon  disappeared.  Graily-Heivitt, 


THE  SEXUAL  EPOCH  OF  THE  MENACME.  235 

in  an  unmarried  woman  twenty-seven  years  of  age,  cured  by  reposi- 
tion of  a  retroflexed  uterus  a  gastric  disorder  which  had  subsisted 
for  nine  years;  Elder  and  Henrik  report  identical  results  in  gastric 
troubles  consequent  on  retroflexion  or  retroversion  of  the  uterus. 
Jaffc,  in  a  virgin,  aged  twenty-three,  who  had  been  brought  near 
to  death  by  gastric  disorder  with  vomiting,  found  on  local  exam- 
ination that  there  was  a  profuse,  thick,  purulent  discharge  from  the 
interior  of  the  uterus ;  curetting,  and  irrigation  of  the  uterine  cavity 
with  antiseptic  solutions,  gave  immediate  relief  to  the  stomach 
trouble.  Similar  experiences  are  recorded  by  C.  van  Tussenbeck  and 
Mendes  de  Leon  in  cases  of  gastric  disorder  consequent  on  en- 
dometritis  fungosa  and  endomctritis  intcrstitialis  parenchymatosa; 
and  by  Gottschalk,  in  cases  consequent  on  sarcoma  of  the  chorionic 
villi.  Leivy  and  Butler-Smythc  have  observed  the  relief  of  per- 
nicious vomiting  by  Emmet's  operation  (trachelorraphy). 

As  regards  the  relations  of  gastro-intestinal  affections  to  the 
diseases  of  the  reproductive  organs,  Theilhaber,  in  the  cases  ob- 
served by  himself,  distinguishes  three  groups.  In  the  first  group 
of  cases,  the  gynecological  abnormality  was  a  chance  accessory, 
and  was  not  the  cause  of  the  gastric  trouble.  In  the  second  group, 
he  regards  the  gynecological  trouble  as  dependent  upon  the  affec- 
tion of  the  gastro-intestinal  tract,  believing  that,  in  consequence  of 
atony  of  the  intestine  and  an  accumulation  therein  of  faeces  and 
flatus,  a  retardation  of  the  circulation  occurs  in  the  region  of  the 
inferior  vena  cava,  resulting  in  venous  stasis  in  the  uterus,  and  so 
giving  rise  to  metrorrhagia,  dysmenorrhcea,  and  fluor  albus.  In 
the  third  group  of  cases,  Theilhaber  believes  that  the  uterine  trouble 
is  the  cause  of  the  disturbances  in  the  stomach  and  intestine.  He, 
like  myself,  has  found  in  all  these  patients  an  inhibition  of  the  in- 
testinal movements ;  but  he  found,  on  the  other  hand,  that  the  gastric 
secretions  were  more  commonly  normal,  and  that  only  in  a  small 
proportion  of  the  cases  was  the  vomiting  centre  excited.  Further, 
in  the  majority  of  these  women,  the  course  of  the  digestive  processes 
was  quite  normal ;  and,  finally,  in  his  series  of  cases,  endometritis 
was  one  of  the  commonest  causes  of  consecutive  gastric  disorders. 
His  observations  led  him  to  conclude  that  "  in  consequence  of  af- 
fections of  the  uterus  a  large  number  of  different  symptom-com- 
plexes of  gastric  trouble  occur:"  the  pure  nervous  dyspepsia  of 
Lcube,  dependent  on  atony  of  the  large  intestine  and  atony  of  the 
stomach,  hyperchlorhydria  and  anacidity,  periodic  gastralgia  without 
anatomical  cause,  etc. 

Cardiopathia  Vienna. 

I  use  the  term  cardiopatlira  utcrina  to  denote  the  manifold  cardiac 
disorders  which  occur  in  women  as  reflex  processes  excited  by  the 


236  THE  SEXUAL  LIFE  OF 

physiological  functions  and  the  pathological  disorders  of  the  genital 
organs,  and  take  the  form  of  very  various  disturbances  of  the  cardiac 
function.  Every  phase  of  the  sexual  life  of  women  —  that  in  which 
the  reproductive  organs  attain  complete  development  and  menstrua- 
tion first  appears  (the  menarche)  ;  the  commencement  of  sexual 
intercourse ;  pregnancy,  parturition,  and  the  puerperium ;  finally  the 
retrogressive  process  at  the  climacteric  age,  of  which  the  menopause 
is  the  outward  manifestation  —  may  give  rise  to  the  occurrence  of 
such  cardiac  troubles.  In  order  to  explain  these  troubles  as  reflex 
in  their  nature,  we  must  on  the  one  hand  recur  to  the  anatomical 
changes  in  the  uterus  and  its  annexa  that  take  place  in  every  one 
of  the  above-mentioned  phases  of  the  sexual  life;  and  on  the  other 
hand  we  must  take  into  consideration  the  mental  processes  that  ac- 
company these  anatomical  changes,  in  order  to  estimate  their  influ- 
ence upon  the  motor  and  sensory  nerves  of  the  heart  (see  the  sec- 
tions on  the  Menarche  and  the  Menopause). 

A  certain  predisposition  to  uterine  cardiopathy  exists  in  many 
individuals  and  in  many  families.  This  predisposition  may  be  mani- 
fested in  this  way,  that  in  women  who  at  the  time  of  the  menarche 
have  suffered  from  cardiac  disorder,  similar  cardiac  disorder  is  likely 
to  recur  at  the  time  of  the  menopause,  the  symptoms  of  the  recur- 
rent attack  being  in  most  cases  identical  with  those  that  occurred 
during  the  menarche.  In  the  well-to-do  and  cultured  circles  of  so- 
ciety, uterine  cardiopathy  is  far  more  frequently  encountered  than 
among  the  working  classes.  Both  unusually  early  and  unusually 
late  commencement  of  menstruation  tend  to  favor  the  occurrence  of 
uterine  cardiopathy.  The  most  valuable  therapeutic  measures  that 
we  can  employ  to  combat  these  disorders  are  suitable  dietetic  and 
hygienic  regulations,  in  association  with  favorable  mental  influences. 

Diseases  of  the  female  reproductive  organs,  including  simple 
functional  disturbances,  are  very  frequently  accompanied  —  far  more 
frequently  than  has  hitherto  been  supposed  —  by  cardiac  disorders. 
But  whereas  in  some  cases  these  cardiac  disorders  are  directly  de- 
pendent upon  the  disease  of  the  genital  organs ;  in  other  cases  no 
such  etiological  relationship  can  be  shown  to  exist,  and  the  associa- 
tion must,  therefore,  be  regarded  as  fortuitous. 

In  cases  of  the  former  kind,  the  dependence  of  the  cardiac  disorder 
upon  the  disease  of  the  genital  organs  is  very  variable  in  its  nature. 

Reflex  manifestations  on  the  part  of  the  nervous  system  may  be 
aroused  by  pathological  changes  in  the  genital  organs,  in  a  manner 
similar  to  that  discussed  in  other  parts  of  this  work  in  regard  to 
the  cardiac  troubles  that  are  liable  to  occur  during  the  menarche 
and  the  menopause ;  such  cardiac  disorders  are  indeed  excited  espe- 
cially by  changes  in  the  ovaries,  by  disturbances  of  menstrual  ac- 


THE  SEXUAL  EPOCH  OF  THE  MENACME.  237 

tivity,  by  suppression  of  the  menses  —  as  manifestations,  that  is  to 
say,  of  the  menstrual  reflex.  The  cardiac  disorder  most  commonly 
takes  the  form  of  tachycardiac  paroxysms,  recurring-  periodically, 
either  in  association  with  the  menstrual  flow,  or,  if  this  is  in  abey- 
ance, at  the  times  at  which  it  ought  to  appear.  We  must  assume 
in  these  cases  that  the  local  stimuli  aroused  by  the  pathological 
changes  in  the  uterus  and  the  ovaries  have  a  reflex  influence  upon 
the  cardiac  nerves,  by  means  of  which  the  heart's  action  is  increased 
in  frequency,  without  inquiring  more  particularly  whether  the  reflex 
influence  is  effective  by  inhibiting  the  normal  action  of  the  vagus, 
or  by  stimulating  the  sympathetic,  or,  perhaps,  by  a  combination  of 
these  factors.  Much  more  rarely  do  we  notice,  in  association  with 
disorders  of  the  reproductive  system,  a  reflex  decrease  in  the  fre- 
quency of  the  heart's  action,  this  effect  being  explicable  in  the  same 
manner  as  the  well-known  experiment  of  Golz,  in  which,  if  the 
abdomen  of  a  frog  be  laid  bare,  and  the  intestine  be  struck  sharply 
with  the  handle  of  a  scalpel,  the  heart  will  stand  still  in  diastole  with 
all  the  phenomena  of  vagus  inhibition. 

In  another  group  of  diseases  of  the  genital  organs,  the  disturb- 
ances of  cardiac  activity  may  be  brought  about  by  pressure  which, 
in  consequence  of  the  morbid  processes  in  the  reproductive  organs, 
is  exercised  upon  individual  nerves  or  upon  an  entire  nerve  plexus. 
Tumefied  and  prolapsed  ovaries,  an  enlarged  and  misplaced  uterus, 
inflammatory  nodules  and  hyperplasias  of  the  intrapelvic  connective 
tissue,  contractile  processes  in  the  parametric  connective  tissue,40 
tumors  of  the  uterus  whether  intramural  or  in  the  interior  of  that 
organ,  ovarian  tumors,  prolapse  of  the  uterus,  and  intrapelvic  peri- 
toneal adhesions  resulting  from  inflammatory  processes  —  these  are 
the  principal  conditions  liable  to  occasion  reflex  cardiac  disorder; 
but  certain  tissue  changes,  such  as  endometritis,  erosions  (chronic 
cervical  catarrh),  and  ulcerations  of  the  genital  passages,  with  or 
without  exposure  of  nerve-endings,  are  also  competent  to  produce 
the  same  effect.  Here  the  sympathetic  nervous  system  constitutes 
the  channel  by  means  of  which  the  stimuli  affecting  the  nerves  of 
the  genital  organs  are  conveyed  to  the  central  nervous  system,  and 
by  means  of  which  also  the  reflex  manifestations  of  this  stimula- 
tion are  produced,  taking  the  form,  partly  of  disorder  of  the  cardiac 
action,  of  palpitation  of  the  heart  and  paroxysmal  tachycardia,  and 
partly  of  pains  in  the  cardiac  region  and  disturbances  along  the 
course  of  the  great  vessels. 

Further,  in  cases  of  long-continued  disease  of  the  female  genital 

*°Ger.  in  den  Paramctrien.  The  reasons  for  preferring  the  phrase  para- 
metric connective  tissue  to  the  noun  parametrium  will  be  found  in  the 
English  edition  of  Toldt's  Atlas  of  Human  Anatomy,  Part  IV,  App.  note  84. 


238  THE  SEXUAL  LIFE  OF  WOMAN. 

organs  associated  with  severe  haemorrhage  and  in  some  cases  fluor 
albus,  nutrition  in  general  and  haemotopoiesis  may  be  seriously  af- 
fected, and  disturbances  of  cardiac  activity  may  result,  as,  for  in- 
stance, is  frequently  witnessed  in  chloro-anaemic  states.  In  such 
cases  we  have  palpitation  of  the  heart,  both  subjective  and  objective, 
a  weak  and  compressible  pulse,  often  irregularity  of  the  heart's 
action,  singularly  clear  heart  sounds,  often,  however,  systolic  mur- 
murs at  various  orifices,  increased  frequency  of  heart  and  respira- 
tion to  a  disproportionate  degree  on  slight  exertion,  strong  pulsa- 
tion of  the  carotids,  and  slight  oedema  of  the  ankles. 

Often,  however,  the  disturbance  of  cardiac  activity  is  dependent 
also  upon  degenerative  processes  in  the  myocardium,  upon  fatty 
degeneration  and  the  consequent  dilatation  of  the  cavities,  this  de- 
generation being  a  consequence  of  the  growth  of  a  uterine  tumor 
and  especially  of  uterine  myomata,  or  resulting  from  some  constitu- 
tional disorder  which  is  itself  dependent  upon  the  affection  of  the 
genital  organs.  In  such  cases  the  signs  of  degeneration  of  the 
heart  are  very  striking:  weakening  of  the  cardiac  impulse,  notable 
faintness  of  the  sounds  of  the  heart,  occasionally  reduplication  of  the 
second  sound,  a  galloping  rhythm,  while  percussion  shows  the  exist- 
ence of  considerable  dilatation  of  the  left,  and  still  more  frequently 
of  the  right  ventricle;  in  many  cases  also  we  have  angina  pectoris, 
passive  hyperaemia  of  the  lungs,  the  mucous  membranes,  and  the 
extremities;  and  sudden  death  sometimes  ensues. 

No  less  important  are  the  mental  influences  exercised  by  diseases 
of  the  genital  organs  in  which  operation  is  proposed  or  actually  per- 
formed, also  by  long-lasting  diseases  of  the  reproductive  organs  and 
by  the  disturbances  these  diseases  produce  in  the  reproductive  func- 
tions, more  especially  in  relation  to  copulation  and  the  actual  process 
of  reproduction.  In  this  way  cardiac  neuroses  of  various  kinds  may 
be  induced. 

Finally,  cases  have  come  under  my  notice  in  which  the  cardiac 
trouble  was  not  the  direct  result  of  the  disease  of  the  genital  organs, 
but  was  a  consequence  of  the  therapeutic  measures  employed  for 
the  relief  of  the  latter;  and*  in  this  connection  I  must  regard  as  espe- 
cially blameworthy,  in  addition  to  intrauterine  manipulations,  such 
as  sounding  and  cauterization,  the  modern  practice  of  gynecological 
massage. 

Not  all  diseases,  however,  of  the  female  reproductive  apparatus, 
tend  in  a  similar  manner  and  with  equal  frequency  to  give  rise  to 
consecutive  cardiac  disorders..  According  to  my  own  observations, 
the  diseases  of  the  vulva  and  the  vagina,  catarrhal  inflammation, 
colpitis  (vaginitis),  leucorrhcea,  and  prolapse  of  the  vagina 
(cystocele  and  rectocele),  are  those  which  most  rarely  induce  cardi- 


THE  SEXUAL  EPOCH  OF  THE  MENACME.  239 

opathy;  unless,  indeed,  the  diseases  just  enumerated  have  led  to  the 
occurrence  of  vaginismus,  for  in  this  latter  condition  cardiac  trouble 
not  uncommonly  ensues.  More  commonly  than  by  vulval  and  vag- 
inal diseases,  cardiac  troubles  are  induced  by  inflammation  of  the 
uterine  mucous  membrane,  as  by  chronic  endometritis,  by  erosion 
and  "  ulceration  "  of  the  cervix  (chronic  cervical  catarrh);  they 
also  sometimes  occur  in  connection  with  perimetritic  and  parametritic 
exudations.  Most  frequently  of  all,  and  most  severely,  cardiac  dis- 
orders are  aroused  by  displacements  of  the  uterus,  flexions  or 
versions;  by  structural  changes  of  the  uterus  accompanied  by  en- 
largement of  that  organ,  such  as  chronic  metritis  and  the  growth  of 
myomata  (especially  intramural)  ;  by  prolapse,  enlargement,  and 
tumor  of  the  ovary ;  by  intrapelvic  exudations  which  when  extensive 
give  rise  to  displacement  or  compression  of  the  uterus  or  its  annexa. 
In  cases  of  carcinomatous  or  other  malignant  new  growths  af- 
fecting the  reproductive  organs,  I  have  in  comparison  very  rarely 
observed  the  occurrence  of  reflex  cardiac  disorders. 

Disturbances  of  menstrual  activity,  amenorrhoea,  menorrhagia,  and 
dysmenorrhcea,  owning  .the  most  varied  causes,  very  frequently  give 
rise  to  cardiac  trouble,  a  point  on  which  we  have  already  insisted. 
(See  page  142,  et  scq.) 

Very  violent  forms  of  cardiac  neurosis  have  been  observed  by 
me  in  women  suffering  from  chronic  disorder  of  the  reproductive 
organs,  who  have  consulted  one  gynecologist  after  another  and  have 
been  subjected  to  many  different  methods  of  local  treatment ;  also 
in  women  who  have  for  a  long  time  suffered  from  some  gynecological 
ailment  hitherto  believed  to  be  trifling,  but  who  have  at  length  sud- 
denly been  informed  that  some  severe  operative  procedure  has  be- 
come necessary.  In  such  cases  the  cardiac  trouble  took  a  paroxysmal 
form,  the  intervals  being  usually  considerable,  several  weeks  or 
months  in  duration,  and  the  general  system  was  as  a  rule  seriously 
involved  in  the  attacks.  These  latter  began  with  severe  cardialgia, 
radiating  from  the  cardiac  region  outward  along  the  intercostal 
spaces,  upward  to  the  shoulder  and  along  the  left  arm,  sometimes 
indeed  extending  into  both  arms.  At  the  same  time  the  heart's 
action  was  greatly  increased  in  frequency,  there  being  sometimes 
more  than  200  beats  per  minute,  the  pulse  was  soft,  small,  difficult 
to  count,  the  respiration  greatly  increased  in  frequency,  sometimes 
very  shallow,  with  respiratory  anxiety,  and  exceptionally  severe 
general  excitement  and  sense  of  impending  death.  In  some  cases 
also  I  observed  spasm  of  various  groups  of  muscles,  dizziness  (with 
a  sense  that  the  objects  of  vision  were  flickering),  aphasia,  and 
mental  stupor.  The  paroxysms  lasted  for  some  time,  two  or  three 
hours,  as  a  rule,  and  gradually  passed  away.  Their  character  was 


240  THE  SEXUAL  LIFE  OF  WOMAN. 

that  of  the  cardiac  disorder  variously  described  under  the  names 
of  pseudo-angina  and  angina  pectoris  hysterica. 

Such  attacks  as  these  are  followed  by  a  sense  of  severe  general 
depression  and  want  of  energy,  and  by  a  decline  in  body  weight. 
They  are  distinguished  from  true  angina  pectoris  by  the  absence  of 
any  signs  of  arteriosclerosis  or  of  degeneration  of  the  myocardium. 
They  may  be  regarded  as  cardiac  disorder  of  duplex  causation,  being 
partly  dependent  on  the  disease  of  the  genital  organs,  which  gives 
rise  to  a  number  of  local  afferent  stimuli,  and  partly  dependent  on 
mental  influences  which  have  a  depressant,  paralyzing  influence  on 
the  cardiac  nerves ;  it  is  possible  also  that  spasmodic  contraction  of 
the  walls  of  the  coronary  arteries  or  of  the  myocardium  itself  is 
induced  as  a  reflex  effect  of  the  local  disorder  of  the  reproductive 
organs. 

With  regard  to  uterine  myoma  as  the  exciting  cause  of  cardiac 
degeneration,  very  numerous  observations  and  experiments  have 
recently  been  made,  and  the  reality  of  the  occurrence  is  no  longer 
open  to  dispute,  even  if  its  significance  is  subject  to  various  inter- 
pretations, whilst  no  satisfactory  explanation  has  yet  been  forth- 
coming. 

L.  Landau  writes  concerning  the  disturbances  induced  in  the 
circulatory  apparatus  by  the  growth  of  myomata  in  the  uterus : 
"  The  formation  of  varices,  the  occurrence  of  thrombosis,  and, 
finally,  the  onset  of  degeneration  of  the  myocardium,  are  very  com- 
mon. Should  the  last-named  process  result  —  and  it  is  truly  alarm- 
ing to  observe  the  frequency  with  which  cardiac  affections  are  as- 
sociated with  uterine  myomata, —  then,  by  a  vicious  circle,  the 
uterine  haemorrhages  become  continually  more  profuse,  in  conse- 
quence of  increasing  passive  hypercemia  dependent  upon  diminishing 
power  of  the  cardiac  pump.  Venous  congestion  in  the  province  of 
the  inferior  vena  cava  results  in  ascites,  and  sometimes  in  general 
oedema ;  and  even  in  cases  in  which  no  increase  of  the  uterine  haemor- 
hages  is  observed,  the  patient  may  succumb  in  consequence  of  sec- 
ondary disease  of  the  heart.  *  *  *  In  the  great  majority  of 
cases,  the  myoma  and  the  uterine  haemorrhages  that  result  from  its 
growth  are  the  primary  cause  of  the  morbus  cordis.  Naturally  in 
cases  which  come  under  observation  only  when  both  uterine  and 
cardiac  disease  are  already  present,  it  is  difficult  to  determine  with 
certainty  the  true  causal  connection.  When,  however,  a  number  of 
patients  suffering  from  uterine  myomata  are  observed,  in  whom  at 
first  the  heart  was  found  to  be  healthy,  and  subsequently  to  have 
become  affected ;  and  when,  on  the  other  hand,  we  see  patients  af- 
fected with  myoma  uteri  in  whom  operation  is  undertaken  notwith- 
standing the  existence  of  cardiac  disease,  and  in  whom,  after  the 


THE  SEXUAL  EPOCH  OF  THE  MENACME.  241 

operation  has  been  successfully  performed,  the  cardiac  murmurs 
disappear  as  well  also  as  the  other  signs  of  heart  disease,  when  dila- 
tation can  no  longer  be  detected,  when  the  pulse-frequency  declines 
to  normal,  whilst  a  previously  feeble  and  compressible  pulse  gains 
in  tension  and  power  —  then  it  is  impossible  to  doubt  that  the  heart 
disease  was  secondary,  and  was  etiologically  dependent  upon  the 
primary  myoma  and  the  uterine  haemorrhages." 

Lehmann  and  P.  Strassmann  examined  the  material  of  the  Charite- 
Policlinik  at  Berlin  in  order  to  throw  light  on  the  relation  between 
uterine  myomata  and  diseases  of  the  heart,  a  connection  already 
proved  to  exist  alike  by  recent  pathologico-anatomical  researches, 
by  clinical  experience  of  the  results  of  operations  (death  from 
shock),  and,  finally,  by  the  subjective  troubles  of  the  patients  (pal- 
pitation, venous  congestion,  giddiness,  and  syncope).  Examining  71 
women  suffering  from  myoma  uteri,  Lehmann  and  Strassmann  found 
in  29  (41$)  that  some  abnormality  existed  in  the  cardiovascular 
system,  such  abnormalities  being  extremely  variable  in  character, 
as  for  instance:  hypertrophy  or  dilatation  of  the  heart,  irregularity 
of  the  cardiac  action,  passive  hyperaemias,  oedema,  albuminuria,  an- 
gina pectoris,  and  cardiac  asthma.  The  next  point  was  to  determine 
the  mutual  relations  between  the  heart  disease  and  the  development 
of  the  uterine  myoma.  Hitherto  it  has  been  assumed  that  the  latter 
is  the  primary  disease,  and  such  a  sequence  is  certainly  the  commoner, 
more  especially  in  cases  in  which  haemorrhage  has  been  profuse,  with 
consecutive  anaemia  and  fatty  degeneration  of  the  heart.  In  these 
cases,  a  certain  time  after  the  commencement  .of  the  severe  haemor- 
rhages, cardiac  troubles  make  their  appearance ;  such  troubles  are 
beyond  question  secondary,  and  they  disappear  as  soon  as  the 
haemorrhage  has  been  controlled.  In  other  patients,  .however,  we 
obtain  a  history  of  the  appearance  of  cardiac  disorder  at  a  date  prior 
to  that  when  any  symptoms  occurred  indicating  the  growth  of  a 
myoma ;  in  these  cases,  therefore,  the  heart  disease  has  developed  in- 
dependently of  the  uterine  disease,  and  has  run  a  parallel  course  to 
the  latter ;  perhaps,  indeed,  by  leading  to  venous  congestion  or  to 
rapid  changes  in  blood-pressure,  the  heart  disease  may  have  favored 
the  growth  of  the  commencing  or  fully  developed  tumor.  In  some 
of  the  patients,  operative  measures  were  followed  by  rapid  recovery 
from  the  cardiac  disorder  (cases  of  simple  anaemia)  ;  in  a  second 
group  of  cases,  however,  the  heart  disease  was  uninfluenced  by 
operation  (cases  of  irreparable  anaemia,  and  cases  of  heart  disease 
independent  of  the  myomata)  ;  and,  finally,  a  considerable  number 
of  patients  remained,  constituting  a  third  group,  in  whom,  notwith- 
standing the  removal  of  the  tumor  by  operation,  the  heart  disease 
continued  to  grow  worse  (cases  of  progressive  heart  disease  inde- 
pendent of  the  myomata,  especially  cases  of  arteriosclerosis). 
16 


242  THE  SEXUAL  LIFE  OF  WOMAN. 

Among  120  women  of  ages  between  17  and  48,  in  whom  I  found 
very  various  functional  disorders  of  or  pathological  changes  in  the 
genital  organs,  and  in  whom  I  made  a  particular  investigation  con- 
cerning the  presence  or  absence  of  heart  disease  and  examined  the 
heart  carefully,  I  was  able  to  detect  the  presence  of  cardiac  troubles 
in  38  instances.  Thus,  heart  trouble  was  found  to  exist  in  32.7  per 
cent,  of  women  suffering  from  disease  of  the  reproductive  organs. 

In  these  38  persons  suffering  from  cardiac  disorder,  I  found: 

Nervous  Tachycardia  in  21  instances,  that  is,  in 

about 55 .2  per  cent,  of  the  cases. 

Hypertrophy  of  the  Heart  in  4  instances,  that  is, 

in  about  10.4  per  cent,  of  the  cases. 

Pseudo-Angina  Pectoris  in  3  instances,  that  is, 

in  about  7.8  per  cent,  of  the  cases. 

Asthenia  Cordis  in  7  instances,  that  is,  in  about.  18.4  per  cent,  of  the  cases. 
Mitral  Incompetence  in  I  instance,  that  is,  in 

about 2.6  per  cent,  of  the  cases. 

Fatty  Heart  in  2  instances,  that  is,  in  about 5.2  per  cent,  of  the  cases. 

As  regards  the  varieties  of  functional  and  organic  disease  of  the 
genitals  met  with  in  the  120  cases,  and  the  number  of  instances  com- 
plicated with  heart  trouble  in  each  variety,  I  found : 

Chronic  Metritis  in  32  patients,  complicated  with  cardiac  dis- 
order in 13  instances. 

Chronic  Oophoritis  in  10  patients,  complicated  with  cardiac 
disorder  in 4  instances. 

Parametric  Exudations  jn  14  patients,  complicated  with  cardiac 

disorder  in 6  instances. 

Chronic  Endometritis  in  16  patients,  complicated  with  cardiac 
disorder  in 2  instances. 

Flexions  and  Versions  of  the  Uterus  in  26  patients,  complicated 
with  cardiac  disorder  in 9  instances. 

Stenosis  of  the  Cervix  in  6  patients,  complicated  with  cardiac 
disorder  in o  instances. 

Tumors  of  the  Uterus  and  its  Annexa  in  8  patients,  compli- 
cated with  cardiac  disorder  in 4  instances. 

Infantile  Uterus  in  3  patients,  complicated  with  cardiac  disorder 

in o  instances. 

Colpitis  (Vaginitis)  in  5  patients,  complicated  with  cardiac  dis- 
order in  o  instances. 

From  these  figures  we  obtain  the  following  percentages,  showing 
the  frequency  with  which  heart  trouble  occurred  as  a  complication 
of  the  respective  diseases  of  the  genital  organs : 

In  Chronic  Metritis,  cardiac  disorder  was  found 

in 40.6  per  cent,  of  the  cases. 

In  Chronic  Oophoritis,  cardiac  disorder  was 

found  in 40  per  cent,  of  the  cases. 

In  Parametric  Exudations,  cardiac  disorder  was 

found  in 42.8  per  cent,  of  the  cases. 

In  Chronic  Endometritis,  cardiac  disorder  was 

found  in  12 . 5  per  cent,  of  the  cases. 

In  Versions  and  Flexions  of  the  Uterus,  cardiac 

disorder  was  found  in 34-6  per  cent,  of  the  cases. 

In  Tumors  of  the  Uterus  and  its  Annexa, 

cardiac  disorder  was  found  in 50      per  cent,  of  the  cases. 


THE  SEXUAL  EPOCH  OF  THE  MENACME.  243 

To  summarize  the  result  of  my  observations  regarding  the  cardiac 
disorders  secondary  to  diseases  of  the  female  genital  organs : 

1.  Tachycardial  paroxysms   in   cases   of  amenorrhoea  were   pre- 
menstrual in  rhythm,  the  paroxysms  occurred,  that  is  to  say,  some 
days  before  the  due  date  of  the  suppressed  flow. 

2.  In  cases  of  dysmenorrhoea,  I  observed  heart  trouble  with  severe 
dyspnoea  and  feelings  of  anxiety,  also  in  some  cases  symptoms  of 
cardiac   asthenia ;   these   symptoms   were   perhaps   dependent   upon 
acute  dilatation  of  the  heart.  The  heart  trouble  associated  with  pro- 
fuse menorrhagia  exhibited  similar  characters. 

3.  Attacks  of  pseudo-angina  pectoris  occurred  in  women  in  whom 
local  treatment  for  disease  of  the  genital  organs  had  been  carried 
out  for  a  long  time,  and  in  cases  in  which  operative  measures  were 
in  contemplation. 

4.  Paroxysms  of  tachycardia  and  cardiac  distress  were  observed 
in  connexion   with   displacements  of  t"he  uterus,  and  especially  in 
cases  of  retroflexion;  also  in  association  with  oophoritis  and  with 
parametric  exudations. 

5.  Cases  of  degeneration  of  the  myocardium,  sometimes  running  a 
rapidly  fatal  course,  were  found  to  be  consecutive  to  tumors  of  the 
uterus  and  its  annexa,  especially  to  myomata  of  the  uterus. 


Nervous  Diseases  Secondary  to  Diseases  of  the  Genital  Organs. 

In  earlier  chapters  of  this  work  we  have  frequently  referred  to 
the  reflex  influence  exercised  upon  the  nervous  system  in  general, 
alike  by  the  normal  functions  and  the  pathological  states  of  the 
female  genital  organs.  We  must  now  briefly  explain  the  more  inti- 
mate connection  between  nervous  diseases  and  diseases  of  the  genital 
organs,  the  causal  dependence  of  local  nervous  disturbances  and  of 
general  neuroses  upon  diseases  of  the  reproductive  organs. 

The  origination  of  a  local  nervous  disease  by  a  primary  disease  of 
the  genital  organs  is  dependent  upon  a  simple  mechanical  process, 
which  is  explained  by  Windscheid  in  the  following  terms :  "  In  this 
connection,  the  two  principal  mechanical  factors  are  pressure  and 
traction.  Pressure  may  affect  individual  nerves  or  an  entire  nerve 
plexus,  and  may  be  exercised  by  a  tumour,  an  exudation  or  a  mis- 
placed organ  (He gar}  ;  further  causes  of  pressure  are  furnished  by 
inflammatory  nodules,  by  connective  tissue  hyperplasias,  and,  ac- 
cording to  Freund,  by  contractile  processes  in  the  organs  them- 
selves and  in  the  ligaments.  Traction  on  the  nerves  results  from 
displacements,  as  from  prolapse  of  the  uterus  or  the  ovaries,  and, 
according  to  Hcgar,  from  traction  on  the  pedicle  of  small  tumours. 
A  combination  of  pressure  and  traction  occurs  especially  in  affections 


244  THE  SEXUAL  LIFE  OF  WOMAN. 

of  the  abdominal  attachments  of  the  uterus,  also  where  there  is 
scarring  of  the  neck  of  the  uterus  and  of  the  vaginal  fornices. 
Great  importance,  also,  in  relation  to  the  production  of  local  nervous 
disorders,  must  be  attributed  to  the  laying  bare  of  nerve-terminals 
by  catarrhal  and  other  inflammatory  processes.  Abnormal  mobility 
of  the  genital  organs  as  a  partial  manifestation  of  enteroptosis 
must  also  be  mentioned  as  a  cause  of  mechanical  stimulation  of  the 
nerves.  Finally,  in  this  connection,  must  be  considered  the  paresis 
of  the  abdominal  walls  that  follows  frequent  and  severe  confine- 
ments." 

The  symptoms  of  the  local  nervous  disorders  to  which  these 
mechanical  stimuli  may  give  rise,  are  very  various,  but  may,  ac- 
cording to  Hcgar,  be  comprised  under  the  general  designation  of 
lumbar  enlargement,  symptoms  (Lendenmarksymptome),  inasmuch 
as  the  local  stimulation  of  the  intrapelvic  nerves,  affects  the  nerve- 
centres  of  the  lumbar  enlargement  of  the  spinal  cord.  Among  the 
symptoms,  severe  pains  are  prominent,  either  continuous  or  inter- 
mittent, within  the  pelvis  and  in  the  sacral  region,  accompanied 
by  a  sense  of  weight  and  pressure  in  the  abdomen,  or  by  dragging 
pain  in  the  region  of  the  hips,  in  the  gluteal  region,  in  the  outer 
and  back  parts  of  the  thighs,  in  the  inner  surface  of  the  leg,  in  the 
calf,  in  the  dorsum  of  the  foot,  the  sole  of  the  foot,  and  the  heel ;  or 
by  coccydynia  (pain  over  the  coccyx  and  the  lower  extremity  of  the 
sacrum),  or  hyperjesthesia  and  anaesthesia  of  the  external  genitals  in 
the  region  of  the  vaginal  orifice,  or,  finally,  by  disorder  of  the  proc- 
esses of  micturition  and  defecation.  In  some  of  these  cases,  the 
weakness  of  the  lower  extremities  is  so  severe  that  a  paralytic  con- 
dition is  simulated.  Actual  paralysis  may  however  occur,  in  con- 
sequence of  the  extension  of  peritoneal  inflammation  to  the  nerve- 
plexuses  of  the  pelvis,  leading  to  the  occurrence  of  neuritis. 

The  development  of  a  general  neurosis  in  consequence  of  disease 
of  the  genital  organs,  either  as  a  complication  dependent  upon  the 
nervous  stimulation  excited  by  the  primary  disease,  or  as  a  reflex 
consequence  of  this  disease,  implies,  as  Windscheid  strongly  main- 
tains, the  existence  prior  to  the  occurrence  of  the  disease  of  the 
genital  organs  of  diminished  power  of  resistance  on  the  part  of 
the  nervous  system.  This  neuropathic  constitution  may  be  the  re- 
sult of  inheritance,  and,  according  to  Engelhardt,  was  so  in  40  per 
cent,  of  his  cases  of  women  suffering  from  nervous  disease  second- 
ary to  the  disease  of  the  genital  organs;  or  it  may  be  acquired. 
Given  this  weakness  of  the  nervous  system,  a  local  disturbance  of  the 
genital  organs  may  act  as  the  ultimate  exciting  cause  of  the  onset 
of  the  neurosis  in  one  of  two  different  ways  (Windscheid}.  "  i.  The 
stimulus  which  the  nerves  of  the  affected  genital  organ  (or  those 


THE  SEXUAL  EPOCH  OF  THE  MENACME.  245 

of  some  adjacent  area,  affected  by  direct  extension)  have  received, 
proceeds  upward  from  segment  to  segment  of  the  spinal  cord,  and 
ultimately  passes  to  the  highest  centres.  2.  Or,  on  the  other  hand, 
the  local  nerves  are  not  directly  involved  in  the  morbid  process  in 
the  genital  organs,  but  this  latter  acts  as  a  source  of  reflex  disturb- 
ance, a  disturbance  which  must  also  pass  through  nervous  channels. 
To  this  latter  class  of  cases  belong  the  instances,  comparatively  so 
frequent,  in  which,  for  example,  a  trifling  retroflexion  of  the  uterus 
must  be  regarded  as  the  exciting  cause  of  the  neurosis."  The  com- 
monest neurosis  of  those  that  may  be  excited  by  local  disease  of  the 
genital  organs  is  undoubtedly  hysteria,  next  in  frequency  come 
chorea  and  epileptic  seizures. 

Schauta  draws  attention  to  the  important  fact  that  hereditarily 
predisposed,  neurasthenic  individuals  bear  very  badly  repeated 
gynecological  examinations  and  long-continued  local  treatment,  in- 
asmuch as,  in  such  persons,  a  notable  increase  in  the  severity  of  the 
nervous  affection  may  result,  and  even  the  outbreak  of  actual  mental 
disorder;  and  he  further  points  out  that  in  hereditarily  predisposed 
individuals,  psychoses  not  infrequently  occur  in  consequence  of  the 
performance  of  gynecological  operations. 

The  processes  of  pregnancy  make  a  deep  impression  on  woman's 
entire  nervous  system,  and  more  especially  on  her  mental  functions. 
This  is  especially  noticeable  in  the  case  of  primiparae.  The  fact  is 
easily  understood,  for  a  woman  is  filled  with  expectation  and  anxiety 
concerning  the  unknown  event,  the  complete  revolution  in  her 
organization,  the  powerful  impressions  on  her  physical  ego,  the 
formation  of  a  new  being  within  her  womb.  How  many  joyful 
hopes,  how  many  distressing  fears,  are  connected  with  that  which 
is  about  to  take  place,  with  the  act  of  creation  within  her  bosom; 
what  changeful  glimpses  into  the  future,  on  the  one  hand  the  glad- 
ness, on  the  other  the  terror,  'of  motherhood  ;  often,  also,  the  anxious 
doubts  as  to  the  probable  sex  of  the  newcomer.  Consider,  too,  the 
stormy  sensations  experienced  by  a  woman  who,  unmarried,  has 
become  pregnant  contrary  to  her  desires  and  expectations,  espe- 
cially one  in  a  poverty-stricken  condition  —  consider  the  agonizing 
thoughts  in  such  a  case  regarding  the  consequences  of  giving  birth 
to  a  child.  It  is  only  to  be  expected  that  in  pregnant  women  in 
general  there  will  almost  always  be  increased  irritability  of  the 
nervous  system  combined  with  a  tendency  to  the  rapid  variation 
of  emotional  states.  Neumann  found,  in  almost  all  the  pregnant 
women  he  examined  in  respect  to  the  point,  that  there  was  an  in- 
crease of  the  knee-jerks,  as  a  manifestation  of  the  general  increase 
of  nervous  irritability.  Nor  does  this  change  depend  upon  mental 
influences  exclusively;  there  are  other  factors,  such  as  the  reflex 


246  THE  SEXUAL  LIFE  OF  WOMAN. 

processes  aroused  by  the  enlargement  of  the  uterus,  and  also  the 
changes  in  the  composition  of  the  blood  which  occur  during  preg- 
nancy, and  cannot  fail  to  have  an  influence  on  the  nutrition  of  the 
brain.  Finally,  also,  the  deposit  of  carbonate  of  lime  on  the  inner 
surfaces  of  the  cranial  bones  (the  parietal  and  frontal  bones) 
which  occurs  during  pregnancy,  may  be  regarded  as  having  some 
casual  connection  \yith  the  changes  in  the  nervous  system ;  and, 
again  many  authors  assume  that  the  cerebral  circulation  is  influenced 
by  the  formation  of  the  placenttal  circulation. 

The  pathological  consequences  of  pregnancy,  as  far  as  they  affect 
the  nervous  system,  take  the  form  of  neuralgia  and  of  peripheral 
neuritis  of  various  nerves,  of  chorea,  of  disturbances  of  the  sense 
organs,  and  of  actual  psychoses. 

Peripheral  neuritis  in  pregnant  women  affects  chiefly  the  lower 
extremities,  but  has  been  observed  in  the  arms  also;  it  is  char- 
acterized by  muscular  wasting  with  reaction  of  degeneration,  by 
trophic  disturbances,  and  by  disorders  of  sensation.  A  cure  may 
ensue  even  during  the  pregnancy,  but  in  other  cases  the  illness  per- 
sists until  after  parturition  and  on  into  the  puerperium.  To  the  same 
cause  Windscheid  assigns  the  parsesthesias  of  pregnancy,  burning, 
prickling,  and  numb  sensations  of  the  finger-tips,  less  commonly 
of  the  toe-tips ;  these  sensations  are  continuous,  not  paroxysmal,  and 
cause  very  great  suffering. 

Pregnancy  favors  the  occurrence  of  chorea,  a  circumstance  ex- 
plicable by  the  increased  irritability  of  certain  nerve  centres  char- 
acteristic of  the  pregnant  woman.  The  chorea  of  pregnancy  occurs 
for  the  most  part  in  primiparae,  it  is  commoner  in  young  than  in 
older  pregnant  women,  and  appears  especially  m  the  early  months 
of  pregnancy.  In  the  majority  of  cases  the  disease  undergoes 
spontaneous  cure  before  the  end  of  the  pregnancy,  but  cases  with 
a  fatal  termination  have  been  observed. 

On  the  other  hand,  a  curative  influence  in  previously  subsisting 
hysteria  has  been  assigned  to  pregnancy.  This  in  fact  only  occurs 
in  cases  in  which  the  hysterical  manifestations  have  been  evoked 
by  influences  which  are  counteracted  or  removed  by  the  occurrence 
of  pregnancy,  such,  for  instance,  as  intense  longing  to  bear  a  child, 
dissatisfaction  with  the  existing  circumstances  of  married  life,  etc. 
Conversely,  it  is  by  no  means  unusual  to  observe  that,  in  patients 
who  have  previously  suffered  from  hysteria,  the  attacks  become  more 
frequent  during  pregnancy,  and  that  other  nervous  disturbances  as- 
sociated with  the  hysteria  become  more  prominent ;  hysterical  pa- 
ralysis, even,  may  appear.  Very  variable  also  is  the  influence  of 
pregnancy  in  epileptics.  Most  commonly,  indeed,  a  certain  quies- 
cence sets  in,  the  attacks  becoming  less  frequent  and  less  severe; 


THE  SEXUAL  EPOCH  OF  THE  MENACME.  247 

but  the  reverse  of  this  is  at  times  observed.  In  the  domain  of 
the  sense  organs  we  observe  amblyopia  and  hemianopia,  deafness, 
and  tinnitus  aurium,  and  disorders  of  taste ;  all  these  appear  as  pure 
nervous  disturbances  without  known  anatomical  basis  (Windscheid}. 

Finally,  among  neuroses,  tetany  may  be  mentioned.  In  women, 
this  disease  occurs  almost  exclusively  during  pregnancy  and  the 
puerperal  state,  in  the  form  of  paroxysmal  spasm,  affecting  chiefly 
ihe  extremities,  and  especially  the  hands;  the  spasm  is  bilateral, 
tonic  in  character,  and  painful.  The  tetany  of  pregnancy  usually 
runs  a  favourable  course. 

The  slighter  forms  of  mental  disorder  consist  of  perversions  of 
taste  and  smell.  Of  actual  psychoses  occurring  during  pregnancy, 
the  commonest  forms  are  melancholia  and  mania.  The  former  con- 
dition, which,  according  to  Ripping,  occurs  in  84.4  per  cent,  of  the 
cases,  is  usually  very  severe,  and  is  characterized  by  a  peculiar 
dreamy  condition ;  it  often  leads  to  suicide,  or  to  infanticide  im- 
mediately after  parturition.  The  psychoses  of  pregnancy  are  seen 
with  greater  frequency  in  the  second  half  of  pregnancy,  they  occur 
especially  in  primiparae,  and  are  also  commoner  in  unmarried  women. 
The  prognosis  is  on  the  whole  an  unfavorable  one;  sometimes,  in- 
deed, the  mental  disorder  terminates  with  the  pregnancy,  but  in 
other  cases  it  continues  during  the  puerperium.  Mental  alienation 
occurring  in  the  early  months  of  pregnancy  is  apt  to  be  less  seVere 
and  to  permit  of  a  more  favorable  prognosis,  than  that  which  makes 
its  appearance  during  the  later  months  or  at  the  end  of  the  pregnancy. 

In  32  cases  of  insanity  of  pregnancy  recorded  by  Ripping,  8  cases 
occurred  in  the  first  pregnancy,  5  in  the  second,  6  in  the  third,  3  in 
the  fourth,  4  in  the  fifth,  I  in  the  sixth,  I  in  the  seventh,  3  in  the 
eighth,  I  in  the  tenth.  Of  these  women 

3  became  affected  in  the  ist  month41  of  pregnancy. 

4  became  affected  in  the  2d  month  of  pregnancy. 

1  became  affected  in  the  3d  month  of  pregnancy. 

2  became  affected  in  the  4th  month  of  pregnancy. 
I  became  affected  in  the  5th  month  of  pregnancy. 
O  became  .affected  in  the  6th  month  of  pregnancy. 

5  became  affected  in  the  7th  month  of  pregnancy. 
5  became  affected  in  the  8th  month  of  pregnancy. 

5  became  affected  in  the  Qth  month  of  pregnancy. 

6  became  affected  in  the  loth  month  of  pregnancy. 

The  neuralgias  of  pregnancy  affect  the  most  diverse  nerve  tracts, 
and  may  occur  either  spontaneously,  without  any  discernible  local 
exciting  cause,  or  in  consequence  of  the  pressure  exercised  by  the 

41  It  is  usual  of  the  Continent  of  Europe  to  divide  the  course  of  pregnancy 
into  ten  "  months  "  of  four  weeks  each.  This  fact  must  never  be  forgotten 
when  comparisons  are  made  between  English  and  Continental  tables,  respec- 
tively, of  the  events  of  pregnancy. 


248  THE  SEXUAL  LIFE  OF  WOMAN. 

enlarging  uterus.  To  the  former  class  of  cases  belong  severe  tri- 
geminal  neuralgia,  the  familiar  toothache  affecting  quite  sound 
teeth  at  the  very  beginning  of  pregnancy,  intercostal  neuralgia,  and 
paroxysms  of  mastodynia.  The  pressure  neuralgias  affect  chiefly 
the  domain  of  the  great  sciatic  nerve,  manifesting  themselves  by 
the  occurrence  of  pain  down  the  back  of  the  thigh,  in  the  calf,  and 
on  the  dorsum  of  the  foot,  sometimes  associated  with  formication 
and  other,  kinds  of  parsesthesia. 

Parturition,  by  its  powerful  effect  on  the  emotional  nature  in 
combination  with  intense  physical  suffering,  may  give  rise  to  numer- 
ous nervous  disturbances.  The  chief  of  these  are,  neuralgia,  oc- 
casioned by  the  pressure  of  the  fcetal  head  as  it  passes  through  the 
pelvis  of  the  mother,  paraesthesias,  convulsions,  maniacal  paroxysms, 
transitory  mental  alienation,  cerebral  haemorrhages,  and  eclampsia. 

The  nervous  disturbances  dependent  upon  the  processes  of  the 
puerperium  are  numerous  and  severe.  According  to  Windschcid, 
four  types  of  affection  of  the  motor  nerves  may  arise  at  this  period. 
I.  Pressure-paralysis  may  occur  in  cases  of  generally  contracted 
pelvis,  or  even  in  the  absence  of  such  contraction  in  cases  of  pro- 
longed labor,  from  the  pressure  exercised  by  the  child's  head  upon  the 
intrapelvic  nerves,  and  above  all  on  the  great  sciatic  nerve  ;  pressure- 
paralysis  may  also  result  from  obstetric  operations,  and  especially 
from  forceps  delivery.  The  symptoms  of  pressure-paralysis  consist 
chiefly  of  paralysis  of  the  extensors  of  the  feet  and  the  toes ;  sensory 
symptoms  are  usually  wanting.  2.  Inflammatory  infective  paralyses, 
due  to  the  extension  to  adjacent  nerves  of  puerperal  inflammation  of 
the  pelvic  connective  tissue.  3.  Acute  multiple  neuritis,  occurring 
either  during  the  latter  half  of  pregnancy  or  a  few  days  after  de- 
livery, and  affecting  not  only  the  nerves  of  the  lower  extremities,  but 
those  of  remote  regions,  even  the  cranial  nerves.  4.  The  rare  puer- 
peral hemiplegia  due  to  cerebral  haemorrhage,  occurring  usually 
at  the  time  the  patient  leaves  her  bed  after  delivery;  puerperal 
hemiplegia  may  also  arise  from  embolism  consecutive  to  endocarditis, 
which  may  itself  have  originated  before  the  termination  of  the 
pregnancy. 

Other  puerperal  diseases  of  the  nervous  system  requiring  mention 
are,  on  the  one  hand,  tetany,  occurring  during  lactation,  and  per- 
mitting of  a  favorable  prognosis,  and  on  the  other,  the  infective 
puerperal  tetanus,  the  prognosis  of  which  is  exceedingly  unfavorable. 
Finally,  the  puerperal  state  has  to  be  considered  as  a  factor  in  de- 
termining the  onset  of  psychoses. 

The  puerperal  psychoses  are  for  the  most  part  dependent  upon 
the  great  loss  of  blood  occurring  during  delivery,  leading  to  anaemia 
and  increased  irritability  of  the  brain,  in  association  also  with  the 


.  THE  SEXUAL  EPOCH  OF  THE  MENACME.  249 

circulatory  disturbances  that  arise  in  the  central  nervous  organs 
in  consequence  of  the  sudden  emptying  of  the  abdomen  by  the 
act  of  childbirth ;  but  additional  causes  of  mental  disorders  are  to  be 
found  in  the  changes  in  the  composition  of  the  blood  that  occur  dur- 
ing pregnancy,  and  the  influence  of  these  changes  upon  the  nutrition 
of  the  brain.  Inherited  predisposition  plays  its  usual  part  in  these 
cases ;  and  accessory  factors  in  producing  mental  disturbance  during 
the  puerperal  state  are  to  be  found  in  puerperal  infection,  eclampsia, 
osteomalacia,  and  emotional  shock. 

Thus,  for  example,  among  49  cases  of  puerperal  psychoses,  Han- 
sen  found  that  in  42  instances  there  was  puerperal  infection ;  and 
among  200  cases  of  puerperal  eclampsia,  Olshausen  found  II  patients 
suffering  from  mental  disorder.  The  principal  forms  of  insanity 
occurring  at  the  puerperium  are  mania  and  melancholia,  next  in 
frequency  come  monomania  (Ger.  Vcrriicktheit},  dementia  (Ger. 
Blodsinn),  alternating  or  circular  insanity  (folie  circulaire) , 
hallucinatory  paranoia  (chronic  delusional  insanity  with  hallucina- 
tions), and  hysterical  mental  disorder. 

According  to  Wmdscheid,  the  commonest  cases  are  those  which  are 
purely  puerperal,  the  rarest  those  in  which  the  insanity  of  pregnancy 
continues  during  the  puerperal  state ;  the  age  at  which  puerperal 
psychoses  most  commonly  occur  varies  between  31  and  35  years,  the 
average  age  being  29.1 ;  multiparae  are  more  often  affected  than 
primiparae ;  the  outbreak  of  mental  disorder  most  commonly  occurs 
within  a  week  after  the  birth  of  the  child ;  there  is  nothing  specific 
about  the  various  forms  of  puerperal  insanity,  which  are  identical 
with  the  respective  varieties  owning  another  etiology.  According 
to*  this  author,  before  an  attack  of  puerperal  mania,  prodromal 
symptoms  usually  occur,  such  as  headache,  dizziness  (Ger.  Augen- 
flinnnern),  feelings  of  anxiety,  insomnia,  followed  by  various  con- 
gestive symptoms,  and  either  by  great  restlessness  or  by  great 
apathy,  and  very  often  by  indifference  to  the  infant ;  to  these  symp- 
toms succeeds  the  period  of  motor  excitability,  characterized  by 
great  bodily  restlessness  and  by  continued  talkativeness ;  the  culmina- 
tion takes  the  form  of  a  maniacal  outburst,  in  which  infanticide 
even  may  occur;  the  delirium  runs  mostly  in  erotic  and  religious 
channels.  Puerperal  melancholia  also  exhibits  the  usual  clinical 
picture  of  this  form  of  mental  disorder ;  after  prodromal  headache, 
stupor  sets  in,  often  associated  with  attacks  of  anxiety  and  with 
hallucinations  of  sense,  and  always  characterized  by  great  loss  of 
appetite  and  by  a  suicidal  tendency. 

In  relation  to  the  puerperal  psychoses,  it  appears  that  the  first 
menstruation  after  the  birth  of  the  child  has,  like  the  very  first 
appearance  of  the  menstrual  flow  during  the  menarche,  a  tendency 


250  THE  SEXUAL  LIFE  OF  WOMAN. 

to  favor  the  onset  of  mental  disorder.  According  to  Marce,  this 
first  post-puerperal  menstruation  has  a  very  definite  significance  in 
the  causation  of  psychoses.  Among  forty-four  cases  of  puerperal 
psychoses,  there  were  eleven  instances  in  which  the  mental  disorder 
made  its  appearance  six  weeks  after  childbirth,  exactly  at  the 
moment,  that  is  to  say,  in  which,  had  the  mothers  not  given  suck  to 
their  children,  menstruation  ought  to  have  reappeared.  In  those 
who  did  not  nurse  their  infants,  and  in  whom  menstruation  recom- 
menced at  the  due  date,  the  psychosis  usually  began  on  the  first  day 
of  menstruation,  less  often  on  the  fourth  or  fifth  day.  In  some 
instances  the  psychosis  appeared  at  the  time  at  which  menstruation 
might  have  been  expected  to  occur,  but  when  the  flow  was  still 
in  abeyance.  And  in  some  women  who  suckled  their  children  for 
a  time  and  then  weaned  them,  the  psychosis  made  its  appearance  at 
the  time  of  the  first  recurrence  of  menstruation. 

Among  diseases  of  the  sense-organs  occurring  during  the  men- 
acme,  ocular  lesions  are  by  no  means  rare  as  sequels  of  pathological 
changes  in  the  genital  organs.  Thus,  in  cases  of  displacements  of 
the  uterus,  especially  prolapse,  retroflexion,  and  retroversion,  we 
sometimes  see  retinal  hyperaesthesia  and  reflex  amblyopia,  pho- 
tophobia and  lachrymation,  and  accommodative  or  muscular 
asthenopia.  Inflammation  of  the  pelvic  connective  tissue,  peri- 
me<tritic  and  parametritic  exudations,  and  especially  parametritis 
atrophicans,may  give  rise  to  functional  disorders  of  the  eye,  reflex 
hyperaemia  of  the  trigeminal  and  optic  nerves,  various  painful  sen- 
sations, and  photophobia.  Severe  metrorrhagia  may  also  cause  dis- 
turbances of  vision,  either  by  inducing  local  anaemia  and  consequent 
functional  failure  of  the  nervous  apparatus,  or  by  leading  to  seribus 
infiltration  of  the  optic  nerve  which  manifests  itself  also  in  the 
retina  in  the  form  of  a  transudation.  In  cases  alike  of  congenital 
and  of  acquired  atrophy  of  the  uterus,  and  frequently,  therefore,  in 
sterile  women,  optic  nerve  atrophy  may  occur. 

COMPETENCE  FOR  MARRIAGE  OF  WOMEN  SUFFERING  FROM  DISEASE. 

In  this  section  we  must  consider  the  competence  for  marriage  of 
women  suffering  from  heart  disease,  of  those  suffering  from  heredi- 
tary tendency  to  mental  disorders  and  neurasthenic  states,  and, 
finally,  of  those  affected  with  tuberculosis. 

Every  doctor  is  confronted  during  the  practice  of  his  profession 
by  the  problem  whether  a  young  woman  known  to  suffer  from  heart 
disease  is  justified  in  entering  upon  marriage  and  in  exposing  her- 
self to  the  dangers  entailed  on  her  diseased  heart  by  copulation, 
pregnancy,  parturition,  and  the  puerperium.  The  solution  of  this 
problem  is  as  important  as  it  is  difficult.  On  the  one  hand,  it  de- 


THE  SEXUAL  EPOCH  OF  THE  MENACME.  251 

termines  the  whole  future  course  of  a  human  life  which  is  still 
ascending  the  upward  path  of  its  vital  career,  and  a  negative  de- 
cision often  annuls  in  a  moment  the  young  woman's  ideals  and 
hopes;  on  the  other  hand,  an  affirmative  decision  involves  the  re- 
sponsibility for  the  consequences  of  marriage,  often  grave  in  these 
cases. 

The  consequences  are  in  fact  apt  to  be  very  serious  indeed.  The 
normal  act  of  intercourse,  in  a  young  and  sensitive  woman,  has 
already  an  exciting  influence  on  the  nerve  apparatus  by  which  the 
movements  of  the  heart  are  controlled.  The  frequency  of  the 
heart's  action  is  greatly  increased,  the  cardiac  impulse  becomes  much 
stronger,  there  is  marked  pulsation  of  the  peripheral  arteries,  the 
conjunctiva  is  injected,  the  respiration  more  frequent.  These  mani- 
festations, which  normally  are  quite  transient,  attain  a  greater  in- 
tensity and  exhibit  a  longer  duration  in  persons  affected  with  heart 
disease.  In  some  instances,  violent  tachycardial  paroxysms  occur, 
with  considerable  dyspnoea,  pains  in  the  cardiac  region,  headache, 
and  even  syncopal  attacks. 

Pregnancy,  in  consequence  of  the  extensive  changes  undergone  not 
only  by  the  reproductive  apparatus  but  also  by  the  general  system,  and 
further  in  consequence  of  the  vital  needs  of  the  developing  embryo, 
involves  extensive  claims  upon  the  cardiac  activity.  It  is  easy  to 
understand  that  the  diseased  heart  must  be  taxed  more  severely 
than  the  healthy  heart  by  the  extension  of  existing  vascular  areas, 
the  addition  of  new  vascular  areas,  and  the  increase  in  the  quantity 
of  the  blood,  during  pregnancy;  and  it  is  not  surprising  if  the  over- 
taxed organ  threatens  sometimes  to  give  way  under  the  strain. 
Thus,  during  pregnancy  in  women  affected  with  morbus  cordis,  we 
observe  numerous  troubles  in  the  way  of  disturbances  of  cardiac 
activity  and  passive  congestion  of  various  organs,  culminating  at 
times  in  abortion. 

Parturition  and  the  puerperium,  moreover,  bring  several  factors 
into  play  which  tend  to  affect  unfavorably  even  a  heart  that  is  quite 
normal ;  and  in  cases  in  which  there  is  disease  either  of  the  heart  or 
of  the  great  vessels,  these  factors  may  lead  to  the  occurrence  of  most 
alarming  symptoms.  In  this  connection  we  may  refer  to  endo- 
carditis, to  fatty  degeneration  of  the  myocardium,  and  to  the  rupture 
of  atheromatous  arteries. 

From  the  time  of  Galen  onwards  all  medical  writers  have  agreed 
that  the  heart  is  unfavorably  influenced  by  pregnancy  and  its  con- 
sequences —  but  from  this  incontestible  proposition  to  deduce  the 
general  conclusion  that  young  women  affected  with  heart  disease 
must  be  forbidden  to  marry  is  in  my  opinion  too  great  a  jump,  and 
altogether  too  sweeping  a  statement.  The  apophthegm  of  Peters,  an 


LLlE-fclE 


THE  SEXUAL  LIFE  OF  WOMAN. 

author  to  whom  we  are  certainly  indebted  for  some  of  our  knowl- 
edge of  the  accidents  grarido-cardiaqncs,  that  in  the  case  of  women 
suffering  from  morbus  cordis  the  rule  must  be  enforced,  fille  pas  de 
manage,  femme  pas  de  grossesse,  mere  pas  d'allaitenicnt,  has  a  fine 
air  of  apodictic  brevity,  but  is  entirely  devoid  of  justification.  No 
such  rigid  prohibition  is  advanced  by  recent  writers  on  heart  disease, 
such  as  Huchard,  von  Leyden,  and  Rosenbach;  not,  at  least,  without 
qualifications. 

The  question  as  to  the  permissibility  of  marriage  to  girls  and 
women  affected  with  heart  disease  cannot,  in  fact,  be  answered 
by  any  general  proposition ;  and  each  case  demands  separate  inquiry 
and  a  careful  balancing  of  individual  considerations.  I  have  known 
cases  in  which  the  marriage  of  young  girls  suffering  from  morbus 
cordis  was  equivalent  to  a  sentence  of  death,  the  execution  of  which 
was  delayed  for  a  few  months  only.  On  the  other  hand,  I  have  known 
many  women  belonging  to  the  upper  classes  and  suffering  from  car- 
diac defects  to  pass  through  numerous  pregnancies  and  to  give  birth 
to  a  number  of  children  with  no  more  than  trifling  disturbances  of 
compensation.  I  am  acquainted  with  a  lady  who  when  a  young 
girl  was  urgently  advised  against  marriage,  on  account  of  extensive 
aortic  valvular  incompetency,  by  two  celebrated  physicians.  The 
advice  was  disregarded,  and  this  lady  is  now  the  mother  of  four 
children,  the  eldest  of  whom  is  twenty-two  years  of  age,  and  her 
general  condition  is  in  no  way  worse  than  it  was  before  her  mar- 
riage. The  dangers  of  marriage  in  women  suffering  from  morbus 
cordis  are  in  my  opinion  generally  overrated. 

The  degree  to  which  a  woman  affected  with  heart  disease  will  be 
injured  by  married  life,  will  depend  on  the  nature  of  the  cardiac 
affection,  on  the  time  it  has  already  existed,  on  the  adequacy  of 
compensation  or  the  intensity  of  existing  disturbances  of  compensa- 
tion, on  the  general  state  of  nutrition  of  the  patient,  on  the  more  or 
less  favorable  social  position,  and  on  the  manner  in  which  sexual  in- 
tercourse is  regulated. 

My  own  opinions  in  respect  of  this  question  may  be  summed  up 
as  follows:  A  woman  who  has  comparatively  recently  (within  a 
few  years)  acquired  a  valvular  defect,  and  in  whom  the  disease  has 
run  such  a  course  that,  in  consequence  of  dilatation  of  certain 
chambers  of  the  heart  and  of  hypertrophy  of  those  segments  of  the 
myocardium  on  which  increased  work  has  been  thrown,  and  thus 
in  consequence  of  adaptation  of  the  cardio-vascular  apparatus  to 
the  new  conditions,  the  circulation  and  distribution  of  the  blood 
take  place  in  a  manner  closely  resembling  that  in  which  these  func- 
tions are  effected  in  a  normal,  healthy  individual  —  in  a  word,  a 
woman  in  whom  the  valvular  disease  appears  to  be  adequately  com- 


THE  SEXUAL  EPOCH  OF  THE  MENACME.  253 

pensatcd, —  if,  in  addition,  the  patient  is  well  nourished,  if  the 
haematopoietic  function  has  not  undergone  any  notable  disturbance, 
if  the  muscular  system  is  powerful  and  the  nervous  system  possesses 
sufficient  power  of  resistance  —  then  marriage  may  be  permitted 
without  hesitation.  In  the  case  of  such  a  girl  or  woman,  we  can 
confidently  assume  that  the  adequate  compensation  of  the  valvular 
disease  will  enable  the  heart  to  meet  with  success  the  claims  made 
upon  its  reserve  energies  by  sexual  intercourse,  by  pregnancy,  and 
by  parturition,  and  that  these  processes  will  not  involve  any  ex- 
cessive danger  to  life. 

A  woman  with  valvular  heart  disease,  even  when  that  disease  is 
well  compensated,  will  indeed  during  pregnancy  and  still  more  dur- 
ing parturition  and  the  early  days  of  the  puerperium,  be  liable  to 
suffer  from  various  manifestations  of  cardiac  disorder.  The  action 
of  her  heart  will  be  subject  to  paroxysmal  increase  in  frequency  and 
force,  sometimes  also  there  may  be  transient  attacks  of  cardiac 
asthenia ;  at  the  same  time  the  breathing  will  become  more  frequent 
and  deeper,  and  occasionally,  even,  there  may  be  severe  dyspnoea. 
Perhaps  also  symptoms  of  venous  congestion  may  manifest  .them- 
selves, digestive  disturbances,  sense  of  pressure  in  the  head,  swelling 
of  the  feet,  oedema  of  the  abdominal  wall,  even  slight  albuminuria. 
Just  after  childbirth,  moreover,  an  abnormally  intense  depression  of 
the  circulation  with  infrequency  of  the  heart's  action  will  be  liable  to 
ensue.  In  the  great  majority  of  cases,  however,  in  which  the  condi- 
tions detailed  above  are  fulfilled,  the  disturbances  of  compensation 
occasioned  by  pregnancy  and  the  puerperal  state  will  not  seriously 
threaten  life;  and  as  soon  as  the  puerperal  period  has  been  safely 
passed  through,  the  heart  will  again  be  competent  for  its  duties  and 
will  do  its  work  as  well  as  before. 

These  statements  apply,  not  only  to  cases  of  well-compensated 
valvular  disease,  especially  mitral  insufficiency,  mitral  stenosis,  and 
aortic  insufficiency,  but  also  to  cases  in  which  the  heart  has  made  a 
good  recovery  after  an  attack  of  pericarditis,  and  to  cases  of  mod- 
erately extensive  disease  of  the  myocardium  consequent  on  acute 
articular  rheumatism  or  the  acute  infections. 

As  indispensable  conditions  for  such  a  favorable  prognosis,  we 
naturally  assume  that  the  pregnant  woman  is  in  a  position  to  com- 
mand the  extreme  bodily  care  that  in  her  condition  is  doubly  need- 
ful, that  she  is  able  to  avoid  all  severe  physical  exertion,  and  that 
she  will  be  subjected  to  continuous  medical  supervision  in  respect  of 
the  adoption  of  suitable  dietetic  and  hygienic  measures. 

Such  a  favorable  prospect  as  regards  marriage  in  cases  of  well- 
compensated  heart  disease  will,  however,  be  clouded  in  the  case  of 
women  who  are  either  very  anaemic  or  predisposed  to  nervous  dis- 
orders; nor  is  the  prognosis  favorable  as  regards  women  in  whom 
the  heart  disease  is  either  congenital,  or  acquired  in  early  youth,  or 


254  THE  SEXUAL  LIFE  OF  WOMAN. 

as  regards  women  contemplating  marriage  when  already  well  up  in 
years. 

For  in  very  anaemic  women,  even  when  the  heart  is  quite  sound, 
frequently  recurring  attacks  of  tachycardia  often  occur  during  preg- 
nancy, in  the  absence  of  any  obvious  exciting  cause ;  oedema  of  the 
lower  extremities,  and  the  formation  of  extensive  varices,  are  also 
common.  Increased  nervous  reflex  irritability  has  also  an  unfavor- 
able influence  upon  cardiac  innervation.  In  cases,  again,  in  which 
the  heart  disease  is  of  long  standing,  the  functional  capacity  of  the 
heart  is  so  notably  depressed  that  the  organ  is  likely  to  prove  in- 
competent to  meet  the  increased  demands  made  upon  it  by  the 
processes  of  pregnancy.  Finally,  in  elderly  women,  superadded  to 
the  valvular  defects,  we  have  the  dangers  dependent  upon  the  already 
beginning  arteriosclerotic  changes  in  the  blood-vessels.  In  all  such 
cases,  therefore,  it  will  be  the  duty  of  the  physician  to  advise  his 
patient  not  to  marry ;  and  in  any  case  to  impress  upon  her  mind  the 
extreme  probability,  amounting  almost  to  certainty,  of  serious  ag- 
gravation of  the  heart  disease  by  marriage,  with  permanent  impair- 
ment of  the  general  health. 

In  cases  of  valvular  disease  accompanied  by  serious  disturbances 
of  compensation,  and  in  cases  of  notable  degeneration  of  the  myocar- 
dium in  which  pronounced  symptoms  of  cardiac  muscular  insuffi- 
ciency have  made  their  appearance,  marriage  must  be  absolutely 
forbidden,  as  directly  imperilling  life.  When  even  moderate  bodily 
exertion  suffices  to  cause  palpitation,  increased  frequency  of  the 
pulse,  and  shortness  of  breath,  when  extensive  oedema  of  the  lower 
extremities  is  present  and  fails  to  disappear  even  after  the  patient 
has  been  strictly  confined  to  bed,  when  the  pulse  very  readily  becomes 
irregular  both  in  rhythm  and  force,  whilst  the  urine  is  often  scanty 
and  contains  variable  quantities  of  albumin,  when  conditions  of 
cardiac  asthenia  readily  arise,  characterized  by  a  small,  irregular 
pulse,  coldness  of  the  extremities,  cyanotic  tint,  nausea,  respiratory 
need,42  and  syncopal  attacks  —  in  all  such  cases,  whether  the  symp- 
toms just  described  are  dependent  upon  valvular  defects,  upon  patho- 
logical changes  in  the  arteries,  or  upon  diseases  of  the  myocardium, 
in  all  alike  the  occurrence  of  pregnancy  is  a  true  disaster,  which  in 
the  vast  majority  of  cases  causes  a  great  and  enduring  aggravation 
of  the  disease,  and  frequently  enough  costs  the  patient  her  life. 

Even  in  such  cases  as  were  previously  described,  in  which,  the 
heart  disease  not  being  severe,  the  patient  was  told  that  marriage 
was  permissible,  it  is  the  duty  of  the  physician  to  lay  down  certain 
rigid  rules  regarding  sexual  activity. 

Women  suffering  from  heart  disease  should  not  have  sexual  in- 

.    Lufthungcr. 


THE  SEXUAL  EPOCH  OF  THE  MENACME.  255 

tercourse  frequently,  because,  if  the  peripheral  nervous  stimula- 
tion of  the  genital  organs  is  excessive  in  consequence  of  too  frequent 
acts  of  coitus,  cardiac  activity  is  likely  to  be  influenced  powerfully 
in  a  reflex  manner,  leading  to  the  occurrence  of  attacks  of  cardiac 
asthenia.  Again,  sexual  intercourse  must  always  be  effected  in 
such  a  manner  that  the  act  attains  its  physiological  conclusion,  and 
that  in  the  woman  as  well  as  in  the  man  the  orgasm  has  its  normal 
outcome,  that  is  to  say  that  at  the  conclusion  of  the  act  the  woman's 
cervical  glands  are  evacuated  with  the  accompaniment  of  the  sense 
of  ejaculation.  The  congressus  intcrruptus,  which  precisely  in  these 
cases  in  which  the  wife  suffers  from  heart  disease  is  so  frequently 
practiced  by  the  husband  with  a  view  to  preventing  conception,  must 
be  strictly  forbidden,  since  this  mode  of  intercourse  tends  to  give 
rise  to  various  forms  of  reflex  cardiac  disturbance,  most  commonly 
to  paroxysms  in  which  the  cardiac  action  becomes  unduly  frequent, 
in  association  with  diminution  of  vascular  tone,  vasomotor  disturb- 
ances, and  states  of  mental  depression ;  and  where  organic  heart 
disease  already  exists,  these  reflex  functional  disturbances  involve 
various  dangers. 

The  physician  is  further  justified  in  advising  that  a  woman  with 
organic  heart  disease  should  not  give  birth  to  more  than  one  or 
two  children.  This  advice  is  the  more  needful  for  the  reason  that 
with  each  successive  pregnancy  the  functional  capacity  of  the 
woman's  diseased  heart  diminishes  according  to  a  geometrical  ratio, 
and  to  a  corresponding  degree  the  danger  to  life  increases.  These 
are  cases  in  which  in  my  opinion  it  is  the  physician's  duty  to  con- 
cern himself  with  the  subject  —  in  general  so  equivocal — of  the 
use  of  preventive  measures,  and,  having  regard  for  the  preservation 
of  a  woman's  life,  and  uninfluenced  by  any  false  delicacy,  but  with 
moral  earnestness,  to  inform  his  patient  with  respect  to  the  needful 
prophylactic  measures.  The  artificial  termination  of  pregnancy, 
which  unquestionably  is  often  justified  in  women  suffering  from 
heart  disease,  but  which  unfortunately  is  apt  to  have  very  unfavor- 
able  results,  will  rarely  need  to  be  discussed  if  by  the  proper  em- 
ployment of  preventive  measures  care  is  taken  that  pregnancy  does 
not  recur  too  frequently. 

To  enable  us  to  answer  the  question  whether,  in  the  case  of  neu- 
rasthenic and  hysterical  young  women,  and  in  those  hereditarily  pre- 
disposed to  the  occurrence  of  mental  disorders,  the  physician  shall 
advise  for  or  against  marriage,  attention  must  in  the  first  instance 
be  directed  to  the  established  facts  relating  to  the  favorable  or  un- 
favorable influence,  as  the  case  may  be,  of  sexual  intercourse  and 
its  consequences  (pregnancy  and  childbirth)  upon  existing  nervous 
disorders  and  upon  the  predisposition  to  their  occurrence. 


256  THE  SEXUAL  LIFE  OF  WOMAN. 

Without  regarding  as  fully  justified  the  opinion  that  in  the  female 
sex  sexual  abstinence  has  in  all  circumstances  an  unfavorable  in- 
fluence upon  the  nervous  system  or  even  that  such  abstinence  is  to 
be  regarded  as  the  principal  cause  of  nervous  and  hysterical  troubles, 
we  must  consider  it  fully  proved  that  in  a  number  of  the  commonest 
varieties  of  nervous  disease  occurring  in  neurasthenically  predisposed 
subjects,  such  as  neurasthenia,  hysteria  and  neurosis  of  anxiety*, 
the  lack  of  sexual  satisfaction  aggravates  these  troubles,  whilst 
suitably  regulated  sexual  intercourse  has  an  actively  beneficial  effect. 
Not,  indeed,  that  it  is  an  infallible  means,  but  none  the  less  the 
effects  are  often  striking,  as  I  have  frequently  had  occasion  to 
observe,  both  in  young  women  so  affected  entering  upon  marriage 
for  the  first  time,  and  also  in  young  widows  who  have  remarried. 
Especially  is  this  true  of  women  in  whom  the  sexual  impulse  is  ex- 
ceedingly powerful,  and  even  pathologically  increased  to  the  extent  of 
marked  sexual  hyperaesthesia ;  likewise  also  in  women  whose  social 
circumstances  and  manner  of  life  induce  increased  sexual  appetite. 
Be  it  understood,  I  refer  here  to  regular  and  moderate  sexual  inter- 
course, and  not  to  sexual  excesses,  which  latter,  by  inducing  nervous 
••xhaustion,  may  have  a  distinctly  deleterious  effect.  In  many  cases, 
however,  we  observe  in  women  suffering  from  sexual  neurasthenia, 
that  sexual  intercourse,  even  when  practiced  at  long  intervals,  gives 
rise  to  nervous  prostration  with  deep  emotional  depression  and  long- 
lasting  aggravation  of  the  existing  nervous  disorder.  This  state- 
ment applies  with  especial  force  to  very  hysterical  epileptic  girls 
with  hereditary  predisposition  to  mental  disorder. 

From  the  fact  that  among  persons  hereditarily  predisposed  to 
mental  disorder,  the  unmarried  are  on  the  average  more  often 
affected  with  insanity  than  the  married,  the  inference  has  been  drawn 
that  marriage  may  be  recommended  to  such  persons  as  a  measure 
likely  to  counteract  their  hereditary  tendency  to  insanity.  The  argu- 
ment, however,  lacks  validity,  more  especially  as  regards  women ; 
among  whom,  moreover,  from  the  age  of  sixteen  to  the  age  of 
thirty,  insanity  is  proportionately  more  prevalent  among  the  mar- 
ried, though  above  the  age  of  thirty  it  is  more  prevalent  among  the 
unmarried. 

In  the  great  majority  of  neurasthenic  women,  normal  sexual  inter- 
course, practiced  in  moderation, has,  according  to  Lowe nf eld,  no  dele- 
terious effect ;  often,  indeed,  as  a  consequence  of  unaccustomed  ab- 
stinence, an  aggravation  of  existing  nervous  troubles  may  be  observed. 
But,  as  this  author  maintains,  nervous  exhaustion  may  result  in  the 
complete  disappearance  of  the  orgasm  during  sexual  intercourse,  or 
in  great  difficulty  in  its  production ;  this  circumstance  suffices  for  the 

*  See  note  36  on  p.  225. 


THE  SEXUAL  EPOCH  OF  THE  MENACME.  257 

most  part  to  explain  the  fact  that  in  women  suffering  from  great 
depression  of  the  nervous  functions,  the  fulfilment  of  their  sexual 
duties  has  sometimes  an  unfavorable  influence  on  their  general 
condition.  As  regards  hysteria,  it  cannot  be  denied,  that  in  manv 
hysterical  women  marriage  results  in  a  favorable  change  in  the 
general  condition ;  we  must,  however,  be  careful  not  to  overrate 
the  significance  of  such  observations.  As  a  rule  all  that  actually 
takes  place  is  a  diminution  in  the  intensity  or  even  a  disappearance 
of  certain  morbid  manifestations  previously  present,  without,  how- 
ever, an  eradication  of  the  hysterical  temperament. 

In  epileptic  young  women,  the  first  experience  of  sexual  inter- 
course may  precipitate  a  fit.  Cases  are  indeed  on  record  in  which, 
in  hereditarily  predisposed  girls,  the  first  coitus  was  the  exciting 
cause  of  the  first  epileptic  fit,  the  fits  recurring  every  time  sexual 
intercourse  was  repeated. 

It  is  a  comparatively  frequent  occurrence  in  psychopathically  pre- 
disposed girls  for  severe  mental  disturbances  to  make  their  appear- 
ance during  the  honeymoon,  after  the  first  experience  of  sexual 
intercourse ;  when  this  occurs,  it  is  doubtless  to  be  accounted  for  by 
the  combined  influence  upon  the  mind  of  all  the  changes  in  the  cir- 
cumstances of  life  which  have  resulted  from  the  marriage.  In  the 
case  of  two  newly-married  women,  one  of  whom  had  well-marked 
hereditary  predisposition,  whilst  in  the  other  there  was  no  known 
family  history  of  mental  disorder,  Loivenfcld  observed  shortly  after 
marriage  the  onset  of  severe  melancholia,  with  refusal  of  food.  The 
delicate,  nervous  temperament  of  these  two  women,  on  the  one  hand, 
and,  on  the  other,  possibly,  a  somewhat  too  eager  and  passionate 
attitude  on  the  part  of  their  respective  husbands,  led  their  first 
experience  of  sexual  intercourse  to  result  in  a  nervous  impression 
of  the  nature  of  shock,  which  their  nervous  system  was  too  weak 
to  resist. 

Frequently  recurring  pregnancy  and  childbirth  may,  according  to 
Kronig,  act  as  the  predisposing  cause  in  the  production  of  neu- 
rasthenia. In  regard  to  hysteria  also  we  must  admit  that  the  onset 
of  some  disease  of  the  organs  of  generation  frequently  leads  pre- 
viously latent  hysteria  to  manifest  itself  openly,  and  further  we  have 
to  recognize  that  diseases  of  the  reproductive  system  often 
give  the  clinical  picture  of  hysteria  a  quite  distinctive  coloration ; 
the  physiological  course  of  the  functions  of  the  generative  organs  is 
also  competent  to  produce  both  of  these  effects.  Kronig,  however, 
rejects  the  view  that  the  lack  of  sexual  intercourse  has  an  unfavor- 
able influence  upon  the  nervous  system  in  women,  and  gives  rise  to 
hysterical  and  neurasthenic  disorders.  The  favorable  influence 
which  marriage  is  often  observed  to  exercise  upon  the  course  of 
nervous  disorders  is  explicable  with  reference  to  psychical  considera- 

17 


258  THE  SEXUAL  LIFE  OF  WOMAN. 

tions  of  a  very  different  nature.  Sexual  abuses,  masturbation,  and 
the  use  of  preventive  measures,  give  rise  in  women  far  less  often 
than  in  men  to  neurasthenic  and  hysterical  conditions. 

Fere  asserts  that  in  certain  neurasthenic  patients  sexual  inter- 
course induces  a  general  blunting  of  the  senses,  and  especially  of 
hearing  and  sight.  Actual  amaurosis  of  short  duration  may  even 
be  observed ;  also  cutaneous  anaesthesias,  paralytic  conditions  of  the 
extremities  taking  the  form  either  of  hemiplegia  or  paraplegia,  con- 
vulsive attacks,  and  somnolent  paroxysms. 

Delasiaui'e  observed  that  epileptic  patients,  who  during  residence 
in  an  asylum  had  remained  almost  entirely  free  from  fits,  after  re- 
turning home  and  resuming  sexual  intercourse,  even  in  strict  modera- 
tion, suffered  from  a  recrudescence  of  the  convulsive  seizures ;  when 
intercourse  was  excessive,  the  relapse  was  naturally  even  more 
severe. 

In  two  instances,  in  women  who  in  a  single  night  had  practiced 
intercourse  to  very  great  excess,  Hammond  observed  paralysis  of 
both  legs  to  ensue ;  he  saw  also  in  numerous  cases  spinal  irritation 
and  other  nervous  disturbances  as  a  consequence  of  sexual  excesses. 

Von  Krafft-Ebing  points  out,  with  reference  to  the  prophylactic 
influence  of  marriage  in  respect  of  mental  disorder,  that  in  men 
early  marriage  diminishes  the  danger  of  the  occurrence  of  such 
disorder,  whereas  in  women  marriage  is  undesirable  before  the  at- 
tainment of  complete  physical  maturity. 

With  regard  to  marriage  in  the  case  of  persons  suffering  from 
nervous  diseases,  Ribbing  lays  down  the  rule  that  when  such  diseases 
have  been  severe  and  have  occurred  in  numerous  members  of  a 
family,  whilst  a  few  only  in  the  family  have  remained  healthy, 
when,  moreover,  the  illness  has  been  accustomed  to  make  its  first 
appearance  only  after  the  attainment  of  maturity,  no  indications  of 
its  onset  being  noticeable  in  childhood  or  youth  —  one  belonging  to 
a  family  thus  afflicted  should  be  advised  not  to  marry.  Where, 
however,  the  hereditary  tendency  is  to  a  disease  likely  to  manifest 
itself  in  childhood  or  youth,  a  member  of  such  a  family  who  has 
been  fortunate  enough  to  p*ass  through  the  years  of  development 
without  exhibiting  any  pronounced  disturbance  of  the  nervous  sys- 
tem, may  be  permitted  to  marry  if  certain  precautions  are  observed. 
A  woman  with  a  tendency  to  alcoholism  should  in  no  circumstances 
be  allowed  to  marry.  In  the  cases,  fortunately  rare,  in  which  the 
drink-craving  exists  in  women,  marriage  is  even  more  undesirable 
than  it  is  in  the  case  of  men  similarly  afflicted,  for  the  female 
drunkard  is  in  a  position  in  which  she  can  mishandle  and  neglect 
her  children  throughout  the  entire  day ;  and,  moreover,  this  affection 
appears  to  be  even  more  obstinately  incurable  in  women  than  it  is 
in  men. 


THE  SEXUAL  EPOCH  OF  THE  MENACME.  259 

Lozvenfcld  very  rightly  insists  that  in  deciding  on  the  advisability 
of  marriage  in  the  case  of  neurasthenic  and  hysterical  girls  the 
anticipated  influence  of  sexual  intercourse  must  not  be  the  sole 
iieterminant.  "  Regulated  sexual  intercourse,  such  as  is  rendered 
possible  by  marriage,  has  often  a  favorable  influence  on  previously 
existing  states  of  nervous  weakness.  But  we  should  go  too  far 
if  we  were  to  attribute  the  beneficial  effect  of  married  life  on  such 
conditions  solely  to  sexual  intercourse.  This  latter  is  but  one  factor 
among  several,  the  others  being  no  less  important.  These  others 
are  :  The  pleasures  of  an  orderly  domestic  activity ;  the  withdrawal 
of  the  patient's  attention  from  her  own  condition,  partly  by  domestic 
duties  and  difficulties,  and  partly  by  the  novelty  of  marital  com- 
panionship; the  gratification,  especially  strong  in  women,  at  having 
obtained  a  support  in  life ;  and,  finally,  the  joyful  expectation  of 
motherfiood.  These  factors,  however,  are  not  present  in  every  mar- 
riage. When  their  presence  cannot  reasonably  be  anticipated,  when, 
:'n  consequence  of  insufficient  means,  the  marriage  is  likely  to  en- 
tail increasing  troubles,  or  when,  owing  to  the  want  of  suitability  of 
temperament,  annoyances  and  quarrels  are  likely  to  occur,  we  must 
throw  the  weight  of  our  advice  into  the  scale  against  the  proposed 
marriage,  since  the  advantages  of  regulated  sexual  intercourse  are 
not  likely  to  outweigh  the  disadvantages  just  detailed.  Even  when 
means  are  ample  and  the  characters  of  the  couple  contemplating 
marriage  are  unquestionably  harmonious,  we  must  nevertheless 
(temporarily,  at  any  rate)  advise  against  marriage,  we.  must,  that 
is  to  say,  advise  the  postponement  of  marriage,  if  the  bride  is  suffer- 
ing from  severe  hysterical  or  neurasthenic  states.  Where,  further, 
such  neurasthenic  or  hysterical  troubles  occur  in  a  woman  with 
pronounced  hereditary  predisposition  to  nervous  disease,  we  must, 
both  for  the  sake  of  the  possible  progeny  and  on  account  of  the 
uncertain  influence  of  married  life  on  the  health  of  the  patient, 
absolutely  and  unconditionally  prohibit  marriage.  In  cases  also  in 
which  severe  hereditary  predisposition  to  mental  disorder  exists 
(especially  when  derived  from  both  parents),  and  in  addition  stig- 
mata of  psychopathic  degeneration  are  actually  apparent  in  the 
patient,  or  she  has  already  suffered  from  the  development  of  a 
psychosis,  we  must  decisively  object  to  the  patient's  marriage." 

As  regards  the  marriage  of  young  women  suffering  from  tuber- 
culosis, we  must  take  into  consideration  a  fact  that  medical  ex- 
perience has  conclusively  established,  namely,  that  the  processes  of 
generation  have  an  unfavorable  influence  upon  pulmonary  phthisis. 
Girls  with  an  inherited  predisposition  to  tubercular  disease,  some- 
times first  manifest  the  symptoms  of  pulmonary  tuberculosis  at  the 
time  of  the  menarche.  In  cases  of  developed  tuberculosis,  copulation 


260  THE  SEXUAL  LIFE  OF  WOMAN. 

and  the  excitement  of  the  vascular  system  associated  therewith  have 
a  more  or  less  unfavorable  influence  —  and  all  the  more  inasmuch 
as,  in  accordance  with  the  saying  oninis  phthisicus  salax,  women 
affected  with  tuberculosis  often  exhibit  a  very  lively  sexual  im- 
pulse, an  almost  insatiable  sexual  appetite.  Sexual  excesses  are, 
moreover,  very  likely  to  lead  to  the  occurrence  of  haemoptysis. 

In  former  days  it  was  believed  that  conception  and  pregnancy, 
when  occurring  in  women  suffering  from  tuberculosis,  had  a  re- 
straining influence  on  the  progress  of  the  pulmonary  disease,  a  view 
which  found  expression  in  the  assertion  of  Batimcs  and  Rozicrcs  de 
la  Chassagne  that  of  two  women  affected  with  tuberculosis  to  the 
same  degree  of  severity,  one  who  became  pregnant  would  always 
outlive  the  other  who  failed  to  become  so.  Careful  and  sufficient 
observations  on  the  part  of  physicians  and  gynecologists  have,  how- 
ever, shown  that  this  view  was  fallacious,  and,  on  the  contrary,  that 
during  pregnancy  tuberculosis  advances  with  more  rapid  strides, 
that  pregnancy,  and  lying-in  accelerate  the  fatal  event  (Grisolle, 
Lebcrt),  that  tuberculosis  acquired  shortly  before  pregnancy  or  in 
the  course  of  that  condition,  progresses  with  exceptional  rapidity 
(Larcher),  and  that  the  lying-in  period  is  especially  perilous  to  these 
patients  (A.  Hanau}.  In  some  cases  of  consumption  it  is  the  first 
pregnancy  that  is  the  most  perilous,  but  in  other  cases  a  later  preg- 
nancy proves  more  destructive. 

Ribbing  goes  even  further,  insisting  that  neither  man  nor  woman 
affected  with  pulmonary  consumption  should  marry.  "  If,  indeed," 
he  writes,  "  consumptives  desire  to  enter  upon  marriage,  merely  with 
the  aim  of  being  faithful  to  one  another  and  assisting  one  another 
for  the  short  time  that  remains  to  them,  I  should  offer  no  opposition. 
But  there  must  be  a  complete  mutual  understanding  of  the  facts 
of  the  case,  and  an  unalterable  determination  on  the  part  of  both  to 
carry  out  the  resolutions  made  prior  to  marriage,  for  failing  this 
the  consequences  will  be  most  disastrous.  In  most  cases,  however, 
the  course  adopted  by  Buhver's  Pilgrims  of  the  Rhine  is  to  be  pre- 
ferred, the  lovers  contenting  themselves  with  the  condition  of  a 
betrothed  pair,  and  in  that  state  awaiting  the  approach  of  death  — 
or,  if  exceptionally  fortunate,  proceeding  to  marriage  only  after 
restoration  to  health." 

It  would  certainly  appear  that  in  the  case  of  girls  suffering  from 
pronounced  phthisis,  we  are  justified  in  advising  against  marriage, 
on  account  of  the  great  danger  which  this  state  entails  of  a  rapid 
advance  in  the  pulmonary  disease. 

Based  upon  the  observations  of  Sch-anta  and  Fellncr,  the  latter  au- 
thor advances  the  rule  that  in  the  case  of  a  woman  suffering  from 
disease,  marriage  should  be  forbidden  only  when  the  mortality  from 


THE  SEXUAL  EPOCH  OF  THE  MENACME.  261 

the  disease  in  question  is  not  less  than  10  per  cent.  In  this  category 
we  must  include  severe  cases  only  of  pulmonary  tuberculosis ;  whilst 
cases  of  laryngeal  tuberculosis  will,  according  to  this  rule,  be  ab- 
solutely unfitted  for  marriage.  Among  heart-affections  contra-in- 
dicating marriage,  he  includes  mitral  stenosis,  other  valvular  affec- 
tions in  which  there  is  serious  disturbance  of  compensation,  and 
myocarditis ;  he  considers  marriage  inadmissible  also  in  cases  of 
chronic  nephritis,  and,  among  surgical  affections,  in  cases  of  ma- 
lignant tumour.  In  cases  in  which  during  a  previous  pregnancy  the 
patient  has  been  affected  by  one  of  the  following  diseases,  viz., 
severe  chorea,  mental  disorders,  severe  epilepsy,  pulmonary  tuber- 
culosis which  progressed  much  during  the  pregnancy,  morbus  cordis 
with  considerable  disturbance  of  compensation,  severe  heart  trouble 
due  to  Graves'  disease  —  in  all  such  cases,  a  repetition  of  pregnancy 
should  be  avoided. 

HYGIENE  DURING  THE  MENACME. 

During  the  sexual  epoch  of  the  menacme  a  woman's  principal 
hygienic  need  is  marriage  completely  satisfactory  alike  to  body  and 
to  mind.  It  cannot  be  denied  that  sufficient  sexual  gratification, 
regular,  of  course,  and  free  from  all  excess,  such  as  is  usually  ex- 
perienced in  married  life,  is  very  advantageous  to  the  health  of  a 
woman  who  has  attained  sexual  maturity  —  even  though  we  admit 
that  the  drawbacks  of  sexual  abstinence,  regarded  as  a  cause  of 
disease  of  the  female  genital  organs  and  the  nervous  system  have 
been  as  a  rule  greatly  exaggerated. 

The  inability  to  marry  always  makes  a  deep  impression  on  the 
mental  life  of  woman,  and  in  many  cases  also  gives  rise  to  burning 
desire  and  tormenting  yearning  of  an  erotic  nature.  The  unmarried 
miss  life's  true  goal  and  fail  to  enjoy  the  natural  exercise  of  their 
functional  capacities ;  alike  in  the  cultured  lady  and  in  the  poor 
working  woman  who  has  failed  to  marry,  the  thoughts  and  feelings 
return  again  and  again  to  her  own  condition  in  a  self-tormenting 
manner. 

The  physical  and  mental  disadvantages  entailed  by  sexual  gratifi- 
cation when  obtained  by  an  unmarried  woman,  one  who,  according 
to  modern  phraseology,  "  wishes  to  secure  her  natural  share  of  the 
joys  of  love,"  and  who  regards  voluntary  chastity  as  "a  sacrifice  to 
meaningless  prejudices  " —  need  not  be  more  particularly  described. 

Free  love,  moreover,  is  the  most  important  disseminator  of 
gonorrhoeal  infection.  "  In  any  future  commonwealth,"  says  Runge, 
"in  which  marriage  is  abandoned  in  favour  of  the  general  practice  of 
free  love,  the  human  race  will  be  overwhelmed  by  gonococci  in  a 
manner  now  hardly  conceivable,  and  the  reproductive  capacity  in 


262  THE  SEXUAL  LIFE  OF  WOMAN. 

both  sexes  will  be  diminished  by  the  results  of  gonorrhoea  to  a  very 
serious  extent." 

Frequently  enough,  also,  free  love  leads  to  prostitution,  which  at 
the  present  day  is  so  widely  prevalent.  Various  reasons  have  been 
suggested  to  account  for  the  increase  of  prostitution.  Among  these 
are :  The  growth  of  modern  industry,  with  the  consequent  aggregation 
of  the  population  in  large  towns ;  the  decline  in  the  marriage  rate ; 
the  postponement  of  marriage ;  universal  military  service ;  the  freer 
mutual  companionship  of  the  sexes ;  and  many  others.  At  any  rate, 
the  fact  would  appear  to  be  established,  that  in  the  case  of  woman 
the  determining  cause  of  prostitution  is  hunger  rather  than  the 
sexual  impulse.  The  worst  paid  classes  of  workwomen  are  shown 
by  official  statistics  to  furnish  the  largest  number  of  recruits  to  the 
ranks  of  prostitutes ;  and  it  is  during  times  of  deficient  employment 
that  the  number  of  women  practicing  occasional  prostitution  in- 
creases. Thus,  material  need  is  the  most  important  of  the  causes 
of  prostitution. 

This  remains  true  even  though  the  doctrine  of  Lombroso  and 
Tamowsky  should  find  fuller  justification,  the  doctrine  that  the 
practice  of  prostitution  by  women  is  the  natural  expression  of  a 
congenital  morbid  predisposition,  "  which  impels  them,  in  defiance 
of  their  direct  advantage,  of  reason,  and  of  all  counter-advice,  to 
adopt  this  accursed  mode  of  life."  Prostitution,  in  this  view,  is  to 
be  regarded  as  the  inevitable  outcome  of  congenital  moral  insanity. 
This  is  certainly  true  of  a  small  proportion  of  prostitutes,  but  is  as 
certainly  false  of  the  great  majority,  in  whom  unfavorable,  difficult 
conditions  of  life  form  the  determining  cause.  A  certain  inherited 
or  acquired  mental  disposition  may,  indeed,  be  assumed  to  exist 
in  these  cases  also  —  an  unstable  moral  equilibrium,  an  insufficient 
development  of  the  force  of  the  will  and  of  the  power  of  resistance. 

The  hygienic  requirement  of  married  life  for  woman  during  the 
menacrhe  is  undoubtedly  sometimes  hard  to  fulfil  in  our  day,  when 
the  more  elaborate  and  expensive  standard  of  life  has  increased  the 
difficulty  of  supporting  a  family ;  but  from  the  medical  point  of 
view  it  is  necessary  to  insist  forcibly  on  this  categorical  imperative, 
in  opposition  to  the  view  advanced  by  the  modern  women's  rights' 
party,  that  "  love  is  moral  also  in  the  absence  of  legal  marriage  " 
(Ellen  Key}  ;  in  opposition  to  the  yet  more  extreme  opinion  of 
George  Sand  and  of  Almquist,  who,  regardless  of  consequences, 
declare  marriage  to  be  immoral ;  and,  finally,  in  opposition  to  the 
advocates  of  "  free  love,"  who  wish  woman  to  be  as  free  as  man 
in  sexual  relations. 

Much  as  we  may  wish  that  man  and  wife  should  be  in  complete 
harmony  in  marriage,  and  that  they  should  feel  themselves  to  be 


THE  SEXUAL  EPOCH  OF  THE  MENACME.  263 

firmly  united  alike  by  mutual  love  and  by  a  reciprocal  sense  of  duty, 
none  the  less  we  must  consider  the  modern  maiden  ripe  for  marriage 
as  unjustified  in  demanding,  before  undertaking  marriage,  '"'perfect 
love  as  typifying  the  inner  yearning  of  two  beings  to  become  one ;" 
and  we  must  regard  the  latter-day  woman  as  extravagant  in  insist- 
ing that  the  man  shall  enter  upon  marriage  in  a  condition  as  virgin 
as  that  of  his  contemplated  wife.  "  Perfect  love  "  is  as  rare  and  as 
little  to  be  expected  as  perfect  beauty;  and  the  sexual  life  of  man 
differs  entirely  in  nature  and  in  the  course  of  its  development  from 
the  sexual  activity  of  women. 

Doubtless  they  spring  deep  from  the  soul  of  woman,  the  demands 
expressed  by  the  writer  of  the  book  "  Vera,"  and  by  her  numerous 
imitators,  the  apostles  of  "  Veraism," —  the  demands  of  the  maiden 
entering  upon  marriage  that  her  husband  shall  be  as  chaste  and 
sexually  as  unspotted  as  herself.  Difficult  of  fulfilment  as  they 
are,  if  fulfilment  is  even  possible,  these  demands  must  none  the  less 
be  regarded  as  characteristic  of  the  sexual  life  of  modern  woman- 
hood. "  Is  man's  sexual  honor,"  exclaims  Vera,  "  then  altogether 
different  from  that  of  woman?  Is  not  the  alleged  necessity  for 
sexual  gratification  in  youth  either  a  well-organized  fraud  or  an 
enormous  error  on  the  part  of  physicians  ?  Is  it  possible  that  chastity 
can  entail  diseases  as  terrible,  as  destructive  to  life  and  happiness  as 
those  that  result  from  unchastity?  And  is  it  not  a  crying  sin,  even 
if  some  of  these  fears  are  justified,  to  ruin  both  mentally  and 
physically  the  whole  race  of  women?  *  *  *  Man  demands  from 
the  girl  of  his  choice,  not  chastity  alone,  but  an  absolutely  un- 
blemished character.  And  rightly  so.  But  the  wife  must  share  her 
husband  with  street-walkers?  She  must  bear  the  pangs  of  maternity, 
while  fortified  by  the  terrible  knowledge  that  the  father  of  her 
children  has  wasted  his  youthful  virility  in  purchased  embraces,  that 
he  has  not  recoiled  from  impurity,  that  he  has  exposed  himself  to  the 
risk  of  infection  with  the  most  horrible  diseases,  that  he  has  squan- 
dered his  virginity  in  the  most  bestial  sensuality?  *  *  *  We 
girls  must  also  be  granted  the  right  to  demand  from  the  man  of  our 
choice  the  same  purity,  the  same  unspottedness  by  sensuality,  that 
he  so  rigorously  demands  from  ourselves !  We  must  no  longer  con- 
tent ourselves  with  the  remnants  that  are  left  for  us  by  others !  We 
must  no  longer  be  satisfied  with  man's  moral  inferiority  I  Then 
there  will  be  more  happiness,  more  love,  more  health  and  joy  of 
life!" 

These  accusations  and  demands  so  boldly  made  are  not  to  be  dis- 
posed of  by  mere  mockery.  With  deep  sorrow  we  must  admit  the 
absolute  truth  of  the  charge  that  too  many  men  clamber  out  of 
the  abyss  of  debauchery  to  a  blighted  marriage.  But  the  demand 


264  THE  SEXUAL  LIFE  OF  WOMAN. 

for  equal  moral  rights,  for  the  abandonment  of  the  hitherto  prevalent 
bisexual  ethical  standards,  is  in  vain  conflict  with  actuality,  with 
the  defensive  instincts  of  young  men,  with  the  difficulties  entailed 
by  the  struggle  for  existence,  with  the  increasing  pretensions  (to 
sexual  freedom)  of  women  themselves;  but  above  all  is  it  in  con- 
flict with  the  thousand-year-old  notions  of  sexual  honor  in  the  male 
and  the  female  respectively,  and  with  the  undeniable  fact  that  the 
mature  man  is  capable  of  elevating  himself  out  of  the  base  intoxica- 
tion of  the  senses  characteristic  of  youth,  to  attain  the  noblest  and 
most  intimate  married  love,  whereas  the  girl  who  has  once  descended 
into  such  an  abyss  sinks  therein  and  is  beyond  the  possibility  of 
rescue.  Thus  early  marriage  with  equal  purity  of  husband  and  wife 
remains  a  postulate  which  the  present  can  hardly  be  expected  to 
satisfy,  and  one  whose  fulfilment  must  be  left  to  the  future. 

In  consequence  of  modern  writings  and  discussions  concerning  the 
erotic  problem,  there  has  arisen  a  hypersensibility  on  the  part  of 
women  in  respect  of  the  conditions  in  which  they  pass  their  mar- 
ried life,  leading  them  to  demand  greater  independence,  a  greater  ex- 
pansion of  their  own  individuality;  this  tendency  must,  however,  be 
resisted,  if  the  marriage  is  to  be  a  happy  one,  with  mutual  comfort 
and  reciprocal  consideration,  one  suitable,  not  for  exceptional  beings 
in  an  ideal  state,  but  for  men  and  women  as  they  really  are.  In  such 
a  marriage,  affection  and  a  sense  of  duty  will  strengthen  love  and 
preserve  fidelity.  A  prudent,  clever  woman  will  always  understand 
how,  notwithstanding  all  necessary  self- surrender,  to  preserve  the 
freedom  of  her  own  individuality  and  the  esteem  of  her  husband. 

Marriages  based  upon' true  inclination  usually  result  in  the  birth 
of  stronger  and  more  beautiful  children  than  marriages  in  which 
the  money-bags  were  the  sole  or  the  principal  determining  cause. 
In  England,  where  people  commonly  marry  when  still  quite  young, 
beautiful  and  healthy  children  are  more  often  seen  than  in  France, 
where  marriages  of  expediency  form  the  great  majority.  According 
to  Bertillon,  of  1,000  young  men  from  20  to  25  years  of  age,  in 
England  120  marry,  but  in  France  less  than  half  that  number,  viz.,  57 
only.  And  100  wives  between  the  ages  of  15  and  40  give  birth 
annually,  in  England  to  39  children,  in  France  to  26  only,  a  number 
less  by  one-third. 

In  deciding  upon  marriage,  hereditary  influences  deserve  careful 
consideration  in  respect  alike  of  the  family  of  the  prospective  hus- 
band and  that  of  the  prospective  wife.  For  it  is  well  established  that 
the  law  of  inheritance  relates  not  only  to  the  peculiarities  of  ex- 
ternal configuration,  to  the  features,  the  stature,  the  tint  of  the  skin, 
but  also  that  children  inherit  from  their  parents  their  mode  of 
bodily  development,  the  functional  activity  of  their  organs,  the  dura- 


THE  SEXUAL  EPOCH  OF  THE  MENACME.  265 

tion  of  their  life,  their  predisposition  to  disease,  and  even  their  in- 
tellectual and  moral  qualities.  As  regards  hereditary  predisposition 
to  disease,  the  most  important  are,  as  is  well  known,  the  predisposi- 
tion to  tuberculosis,  that  to  malignant  tumors,  and  that  to  mental 
disorders. 

Great  disparity  in  the  respective  ages  of  prospective  husband  and 
wife  entail  various  kinds  of  unsuitability  for  marriage.  An  elderly 
man  who  marries  a  young  girl,  even  if  he  still  possesses  a  certain 
amount  of  virility,  is  unlikely  to  procreate  healthy  and  powerful 
children ;  and  these  latter  for  the  most  part  will  be  weakly,  scrofulous 
cachectic,  endowed  with  deficient  powers  of  resistance,  and  often 
badly  equipped  from  the  intellectual  standpoint.  Similar  considera- 
tions prevail  in  respect  of  marriages  in  which  the  husband  has  been 
exhausted  by  earlier  sexual  excesses,  so  that  he  retains  no  more 
than  remnants  of  virility,  whilst  his  semen  is  of  doubtful  fertilizing 
power.  D.  Richard  relates  that  Louis  XIV  asked  his  physician  why 
it  was  that  the  children  he  (the  king)  had  by  his  wife  were  delicate 
and  deformed,  whilst  those  he  had  by  his  mistresses  were  beautiful 
and  powerful.  "  Sire,"  was  the  answer,  "  c'est  parce  que  vous  ne 
donnez  a  la  reine  que  les  rincures." 

Plato  maintains  that  before  every  marriage  the  man  and  the 
woman  should  both  undergo  official  examination  to  determine  their 
fitness  or  unfitness  for  the  married  state,  the  man  being  absolutely 
nude,  and  the  woman  stripped  to  the  waist,  for  the  examination. 
This  author  goes  so  far  as  to  regard  it  as  "  a  form  of  homicide  for 
a  man  to  embrace  a  woman  when  he  is  incapable  of  fertilizing  her." 
How  rarely  it  happens  in  our  day,  however,  that  the  physician,  the 
official  with  the  requisite  knowledge  to  fulfil  Plato's  requirements, 
is  asked  for  his  opinion  regarding  the  desirability  of  a  contemplated 
marriage!  The  only  occasion  on  which  this  is  likely  to  occur  is 
when  a  man  intending  to  marry  wishes  to  be  assured  that  he  is  com- 
pletely cured  from  an  earlier  infection  with  syphilis,  and,  there- 
fore, runs  no  risk  of  transmitting  the  disease  to  his  wife  or  to 
possible  offspring.  But  it  never  occurs  to  the  parents  of  a  girl  about 
to  marry  to  ask  the  physician  whether  she  is  physically  suitable  for 
marriage. 

In  deciding  on  marriage,  however,  care  should  before  all  be  taken 
to  determine  that  the  girl  has  attained  complete  physical  and  espe- 
cially complete  sexual  development.  The  age  at  which  woman  at- 
tains complete  sexual  maturity  is  in  our  climate  and  race  coincident 
on  the  average  with  the  twentieth  year  of  life. 

For  the  hygiene  of  marriage  it  is  necessary  that  the  bride  should 
not  be  extremely  youthful.  Notwithstanding  the  fact  that  the  legal 
codes  of  civilized  countries  nowhere  demand  for  girls  a  greater  age 


266  THE  SEXUAL  LIFE  OF  WOMAN. 

than  fifteen  years  before  permitting  marriage,  this  limit  is,  generally 
speaking,  fixed  far  too  low.  Before  becoming  a  wife,  the  girl  should 
not'  merely  have  attained  complete  physical  development,  with  her 
reproductive  organs  in  a  state  of  maturity,  but  she  must  also  be 
developed  intellectually  to  such  an  extent  that  she  is  fully  capable 
of  understanding  the  nature  and  significance  of  marriage.  At  the 
£<ge  at  which  marriage  is  legally  permissible,  a  girl  is  still  far  from 
having  attained  physical  and  mental  ripeness  for  marriage,  repro- 
duction, and  maternity. 

Especially  with  reference  to  the  last  consideration  is  it  inadvisable 
that  in  our  climates  a  girl  should  marry  earlier  than  from  1 8  to  20 
years  of  age,  and  preferably  even  she  should  first  attain  the  age  of 
from  20  to  22.  In  that  case  her  happiness  as  a  mother  will  be  more 
secure,  'and  there  will  be  a  greater  probability  of  her  producing  a 
healthy  progeny.  In  the  East,  indeed,  quite  different  views  prevail. 
According  to  the  laws  of  Manns,  a  girl  might  marry  on  attaining 
the  age  of  eight  years;  if  within  three  years  thereafter  her  father 
failed  to  provide  her  with  a  husband,  she  might  choose  one  for 
herself.  Among  the  Hindus  it  is  regarded  as  a  disgrace  to  the 
parents  if  a  girl  does  not  marry  quite  young,  indeed  before  the  first 
appearance  of  menstruation.  Atri  and  Kasypa  state  that  if  a 
girl  begins  to  menstruate  before  she  leaves  her  father's  house,  the 
latter  must  be  punished  as  if  he  had  destroyed  a  foetus,  while  the 
daughter  herself  loses  caste.  Marriage  delayed  till  after  the  appear- 
ance of  menstruation  being  regarded  as  sinful,  girls  are  married 
while  still  children,  in  order  to  prevent  the  loss  of  mature  ova,  which 
is  regarded  as  equivalent  to  infanticide.  Very  early  marriage  has 
thus  in  India  been  legally  ordained  for  thousands  of  years.  The 
Hindus,  who  even  now  regard  every  menstruation  which  has  not 
been  preceded  by  coitus  in  the  light  of  infanticide,  marry  their 
daughters  before  the  age  of  puberty. 

According  to  oriental  tradition,  Mahomet  married  Khadijah  when 
five  years  of  age,  and  cohabited  with  her  three  years  later.  In  the 
Bible,  numerous  similar  examples  are  recorded.  Among  many 
savage  tribes,  as,  for  instance,  among  some  of  the  aborigines  of 
India,  and  among  the  indigens  of  Australia,  copulation  is  usually 
effected  before  girls  reach  the  age  of  puberty;  in  India,  indeed, 
according  to  Ploss  and  Battels  (Das  Wc\b  in  dcr  Xatiir  mid  J'ol- 
kerkunde),  marriage  with  immature  girls  is  a  widely  diffused 
custom,  and  in  Australia  a  child  of  ten  or  eleven  is  often  found  to 
be  the  wife  of  a  man  of  fifty  or  the  concubine  of  a  sailor.  In  general, 
according  to  these  authors,  we  find  that  the  age  of  nubility  in  girls 
is  lower  in  proportion  to  the  lowness  of  the  stage  of  civilization 
attained  by  the  race  or  people  to  which  they  belong.  Among  the 


THE  SEXUAL  EPOCH  OF  THE  MENACME.  26? 

ancient  Romans,  girls  were  commonly  married  between  the  ages  of 
thirteen  and  sixteen  years. 

In  the  Talmud,  Rabbi  Joshua  gives  the  following  advice  regard- 
ing early  marriage  in  Jewish  girls :  "  If  your  daughter  has  attained 
puberty  and  is  twelve  yeairs  and  six  months  old,  she  must  be  married 
at  any  cost.  If  no  other  means  are  available,  manumit  one  of  your 
slaves,  and  give  her  to  the  freedman  to  wife." 

Experience  proves,  however,  that  in  our  climate,  at  any  rate,  girls 
who  marry  at  a  very  early  age  are  inferior  in  fertility  to  those  who 
refrain  from  marriage  until  the  genital  organs  have  attained  com- 
plete maturity;  and  statistics  show  that  those  women  who  marry 
before  attaining  the  age  of  twenty  must  wait  longer  for  their  first 
pregnancy  than  those  who  marry  between  the  ages  of  twenty  and 
twenty-four.  At  the  higher  age  also,  women  bear  parturition  and 
its  consequences  more  easily  than  those  who  marry  very  young. 
A  similar  influence  in  marriage  to  that  resulting  from  undue  ju- 
venility is  exercised  by  its  opposite,  marriage  when  a  woman  is 
already  elderly;  in  this  ease  fertility  is  limited,  and  health  also  is 
especially  apt  to  suffer.  When  the  indications  of  the  climacteric 
are  clearly  apparent,  marriage  is  contra-indicated,  not  only  on  ac- 
count of  the  impossibility  of  fertilization,  but  also  in  respect  of 
its  general  unsuitability  in  the  closing  stage  of  the  sexual  life. 

Not  only  is  the  absolute  age  of  the  woman  of  importance  in  decid- 
ing on  the  advisability  of  marriage,  but  the  relative  ages  of  the 
proposed  husband  and  wife  must  also  be  taken  into  account,  first 
of  all  in  respect  of  the  wife's  possible  fertility,  and  secondly  in  re- 
spect of  her  general  health.  The  most  suitable  arrangement  is  that 
in  which  there  is  no  marked  difference  in  age.  The  husband  may 
be,  and  indeed  in  existing  social  circumstances  almost  necessarily  is, 
somewhat  older  than  his  wife,  as  much  perhaps  as  eight  or  ten 
years.  But  a  very  great  disparity  of  age  (in  either  direction)  is  a 
serious  error.  If  a  very  young  girl  marries  an  elderly  man,  or  a 
developed  matron  marries  a  young  man,  the  true  purpose  of  mar- 
riage is  unfulfilled,  the  eternal  laws  of  nature  and  all  ethical  princi- 
ples are  infringed.  In  the  breeding  of  animals,  the  fundamental  prin- 
ciple has  long  prevailed  that  the  animals  chosen  for  coupling  should 
be  well  suited  each  to  the  other  and  should  be  in  perfect  physical 
condition ;  and  breeders  are  also  familiar  both  with  the  favorable 
influence  of  good  nourishment  and  with  the  advantage  of  the  op- 
portune crossing  of  distinct  varieties.  The  same  principles  are 
equally  applicable  to  the  human  race,  neglected  as  they  commonly 
are  in  practice. 

With  regard  to  the  marriage  of  near  kin,  we  can  only  remark 
that  the  marriage  of  those  closely  related  by  blood  should  as  far 


268  THE  SEXUAL  LIFE  OF  WOMAN. 

as  possible  be  avoided,  and  that  such  a  marriage  must  be  absolutely 
prohibited  when  in  both  families  there  is  a  history  of  tuberculosis, 
mental  disorders,  diabetes,  and  the  like.  When  first  cousins  con- 
•  template  marriage,  it  is  indispensable,  not  only  that  both  individuals 
should  be  in  perfect  health,  but  also  that  on- neither  side  there,  should 
be  any  serious  family  history  of  transmissible  disease  or  transmissible 
morbid  tendency;  and,  further,  it  is  absolutely  necessary  that  no 
such  marriage  of  near  kin  should  have  taken  place  in  the  proximate 
ancestry  of  the  cousins,  i.  e.,  their  cousinship  must  not  be  a  double  one, 
derived  both  from  the  paternal  side  and  the  maternal.  It  is  indeed 
to  be  recommended,  with  a  view  to  the  production  of  a  healthy  and 
powerful  posterity,  that  marriage  should  bring  about  a  crossing  of 
healthy  individuals  proceeding  from  different  families,  different 
places,  and  different  constitutional  types.  An  instance  of  the  ad- 
vantage to  be  found  in  this  practice  is  pointed  out  by  Ribbing,  who 
shows  that  the  most  powerful  aristocracy  in  Europe,  that  of  Eng- 
land, by  the  gradual  creation  of  new  peers,  on  the  one  hand,  and 
by  the  gradual  decline  of  younger  sons  and  their  descendants  into 
the  middle  class,  on  the  other,  has  undergone  a  continual  crossing 
with  less  exalted  but  originally  sounder  stocks ;  in  this  way  its  vigor 
and  fertility  have  been  maintained,  .in  contrast  to  the  nobility  of 
many  continental  states,  which  has  so  largely  perished,  in  conse- 
quence of  its  exclusiveness  in  the  matter  of  marriage. 

"  In  this  connection,"  continues  Ribbing,  "  we  must  bear  in  mind, 
that  blood-relationship  is  not  the  only  matter  that  has  to  be  con- 
sidered ;  in  the  interest  alike  of  the  family,  and  of  society,  it  is  neces- 
sary to  demand  that  certain  degrees  of  relationship  by  marriage 
alone,  should  fall  within  the  '  prohibited  degrees '  of  love  and 
marriage.  There  are  certain  groups  related  by  marriage  and  held 
together  by  the  bond  of  affection,  from  which  foster-parents  and 
guardians  may  most  suitably  be  selected  to  fulfil  the  duties  as  re- 
gards education  and  training  of  children  who  have  been  orphaned  in 
early  years.  For  such  a  purpose  none  seem  better  adapted  than  the 
brothers  and  sisters  of  the  deceased  parents ;  but  the  upbringing  of 
the  children  can  be  confidently  entrusted  to  the  former  only  if  the 
relationship  between  the  older  and  the  younger  branches  of  the 
family  is  one  regarded  by  law,  and  still  more  by  morality  and 
custom,  as  one  precluding  the  possibility  of  the  occurrence  of  sexual 
love  and  marriage." 

Mobius,  writing  on  "  The  Ennobling  of  the  Human  Race  by  Se- 
lection in  Marriage,"  observes :  "  The  most  important  aim  of 
natural  development  is  the  perfection  of  humanity.  The  qualities 
of  the  coming  generation  depend  for  the  most  part  upon  the  qualities 
of  the  parents.  Marriage  from  affection  ensures  the  fulfilment  of 


THE  SEXUAL  EPOCH  OF  THE  MENACME.  269 

nature's  aims  with  more  security  than  marriage  from  reason;  since 
what  we  have  to  think  of  is  not  the  happiness  of  the  married  pair 
but  the  quality  of  their  children.  Of  great  importance,  also,  to  the 
development  of  the  human  race  are  the  conditions  during  the  com- 
mencement of  life,  and  the  mode  of  education.  The  improvement  of 
the  race  has  not  hitherto  been  the  conscious  aim  of  the  generality  of 
people.  The  law  does  not  as  yet,  as  it  should,  take  into  account 
the  advantage  of  posterity.  Capital  punishment  is  fully  justified 
and  purposive.  Criminals  should  not  be  allowed  to  marry.  The 
perpetuation  of  disease  by  inheritance  should  be  checked  by  the  ut- 
most powers  of  the  state.  Any  one  marrying  while  suffering  from 
any  venereal  disease  still  in  an  infective  condition  should  be  pun- 
ished. The  marriage  of  persons  suffering  from  tuberculosis  should 
be  prohibited.  Fof  the  prevention  of  disease  is  more  important  than 
its  cure.  The  most  important  factor  in  preventive  medicine  is  an 
improvement  in  the  conditions  of  life.  The  human  ideal  should  be, 
goodness  of  heart  in  association  with  physical  and  mental  health. 
Goodness,  beauty,  and  strength  should  be  simultaneously  pursued. 
Since,  however,  man  is  made  by  birth  far  more  than  by  education, 
selection  in  marriage  is  of  fundamental  importance.  In  the  choice 
of  a  partner,  attention  is  rightly  paid  to  beauty,  since  beauty  and 
health  are  fundamentally  identical ;  moreover,  a  human  being  en- 
dowed with  beauty  is  usually  also  more  moral  than  one  devoid  of 
that  attribute.  Equality  of  birth  is  as  a  rule  desirable  in  marriage ; 
but  not  the  family  only  is  to  be  considered  in  determining  the  exist- 
ence of  such  equality,  individual  characteristics  must  likewise  be 
taken  into  account.  Whether  the  crossing  of  races  is  desirable  is 
not  yet  certainly  determined." 

From  the  hygienic  standpoint  it  is  necessary  that  in  marriage 
also  the  frequency  and  the  manner  of  sexual  intercourse  should  be 
regulated. 

Wise  men  and  law-givers  of  all  the  nations  of  antiquity  have  in- 
sisted upon  the  necessity  of  certain  intervals  between  the  acts  of 
intercourse.  Thus,  Mahomet  prescribed  8  days,  Zoroaster  9  days, 
Solon  10  days,  Socrates  also  10  days.  Moses  forbade  intercourse 
during  menstruation  and  for  a  week  after  the  cessation  of  the  flow. 
Luther  prescribed  intercourse  "  twice  a  week." 

Birds  and  many  mammals  are  competent  to  perform  intercourse 
at  exceedingly  short  intervals.  A  well-bred  cock  will  repeat  this 
act  50  times  daily;  a  sparrow,  20  times  in  an  hour;  a  bull,  3  to  4 
times  in  an  hour.  In  the  human  species,  however,  too  rapid  repeti- 
tion of  intercourse  is  deleterious  not  only  to  the  male,  but  to  the 
female  also,  though  the  latter  certainly  suffers  in  less  degree.  For 
in  this  act  the  female  plays  a  more  passive  part,  and  for  this  reason 


270  THE  SEXUAL  LIFE  OF  WOMAN. 

can  repeat  it  with  impunity  more  frequently  than  the  male,  who 
loses  semen  at  each  repetition.  It  is  not  possible,  however,  to  lay 
down  precise  rules  as  to  the  permissible  frequency  of  intercourse 
in  either  sex;  the  matter  must  depend  upon  physical  needs.  Mod- 
erate and  regular  indulgence  in  sexual  intercourse  is  unquestionably 
advantageous  to  women  both  physically  and  mentally,  regulating  all 
the  functions  of  the  body,  and  tending  to  produce  a  contented  and 
cheerful  frame  of  mind. 

During  menstruation,  a  woman  should  refrain  from  intercourse. 
By  the  Mosaic  law  the  death  punishment  was  allotted  both  to  the 
man  and  to  the  woman  who  indulged  in  coitus  while  the  latter  was 
menstruating.  As  a  matter  of  fact,  considerations  alike  of  hygienic 
cleanliness  and  of  sanitary  precaution  prohibit  the  performance  of 
coitus  during  this  period..  Severe  menorrhagia,  perimetritic  irrita- 
tion, and  parametritic  inflammations,  have  been  observed  to  follow 
such  indiscretions.  On  the  other  hand,  it  is  more  than  doubtful 
whether,  in  the  event  of  pregnancy  resulting  from  intercourse  per- 
formed during  menstruation  (and  conception  is  especially  apt  to 
occur  at  this  time),  the  child  is  likely,  as  earlier  authors  maintained, 
to  be  unfavorably  affected,  and  to  suffer  from  cachexia,  scrofula, 
or  rickets. 

After  the  act  of  intercourse,  a  woman  should  rest;  and  indeed 
sleep  for  some  hours  is  especially  to  be  recommended.  A  vaginal 
douche  should  not  be  administered  until  several  hours  have  elapsed, 
otherwise  there  will  be  a  risk  of  preventing  fertilization  of  the 
ovum.  The  water  employed  for  vaginal  irrigation  should  never  be 
quite  cold;  a  temperature  of  79°-82°  F.  (26°-28°  C.)  is  best. 

All  measures  for  the  purpose  of  artificially  increasing  sexual  de- 
sire, such  as  alcoholic  beverages  (especially  champagne),  and  certain 
drugs  (especially  cantharides),  are  even  more  harmful  to  women 
than  they  are  to  men.  The  woman  who  conceives  while  in  a  state 
of  intoxication  commits  a  great  sin  against  the  coming  generation.43 
Just  as  harmful,  however,  are  the  anaphrodisiacs  sometimes  em- 
ployed to  diminish  the  intensity  of  sexual  desire  when  this  cannot  be 
gratified.  When  affected  with  intense  sexual  excitement,  a  woman 
is  much  more  unfavorably  situated  than  a  man,  since  man  claims 
the  right  to  indulge  in  sexual  intercourse  whenever  he  feels  disposed, 

48  The  statement  is  so  often  made  that  conception  occurring  when  one  or 
both  parents  are  intoxicated  is  likely  to  be  harmful  to  the  offspring,  that  it 
seems  expedient  to  point  out  that  neither  the  author  of  this  work,  nor  any 
other  author  known  to  me,  has  ever  brought  forward  any  rigorous  scientific 
evidence  in  proof  of  the  alleged  fact.  It  is  one  of  those  crude  generalizations 
whose  superficial  verisimilitude  leads  to  their  continued  though  unsupported 
reassertion.  The  fact  that  the  notion  of  procreation  by  inebriated  progenitors 
is  repugnant  to  our  aesthetic  sensibilities  has,  of  course,  nothing  whatever 
to  do  with  the  logical  proof  of  the  assertion  that  such  an  act  is  harmful  to  the 
fruit  of  conception. —  TR. 


THE  SEXUAL  EPOCH  OF  THE  MENACME.  271 

and  has,  moreover,  ample  opportunity  for  sexual  gratification.  A 
woman,  however,  properly  endowed  with  self-respect,  will  under- 
stand how  to  bridle  her  senses.  Bodily  exercise,  moderate,  unstimu- 
lating  diet,  intellectual  occupation  with  serious  matters,  the  avoid- 
ance of  equivocal  literature  and  of  sensual  dramatic  representa- 
tions, cold  bathing,  and  the  use  of  a  hard  mattress  and  light  bed- 
clothing —  these  means  will  cooperate  powerfully  toward  the  pre- 
vention of  excessive  sexual  desire.  Horace  already  remarked: 
"  Otia  si  tolles,  periere  Cupidinis  arcus." 

The  wife  should  know  how  to  bridle,  not  her  own  desires  only, 
but  also  those  of  her  husband.  She  must  not  demand  too  much 
during  the  intoxication  of  youthful  vigor ;  she  must  prevent  the  com- 
plete combustion  of  the  flames  of  masculine  passion,  and  must  keep 
sparks  glowing  in  the  ashes.  Economy  during  the  sexual  prime 
preserves  sexual  power,  enables  a  man  to  continue  intercourse  to  a 
ripe  age,  and  avoids  premature  exhaustion  and  satiety.  When  the 
husband  is  drawing  near  the  end  of  his  sixth  decade,  the  wife  must 
accustom  herself  to  see  in  him  rather  the  father  of  her  children 
than  her  own  husband,  and  must  reduce  her  sexual  demands  to  that 
measure  which  will  not  be  injurious  to  his  health.  Demosthenes, 
writing  of  the  sexual  life  of  the  Athenians  of  his  time,  said :  "  In 
order  to  obtain  legitimate  offspring  and  .to  provide  a  faithful 
guardian  of  our  household,  we  marry  a  wife;  for  our  service  and 
for  the  performance  of  daily  household  duties,  we  keep  concubines ; 
for  the  joys  of  love,  we  seek  the  hetairai."  The  task  is  extremely 
difficult,  but  a  clever  and  virtuous  modern  wife  must  endeavor  to 
combine  in  her  single  personality  the  sensual  attractiveness  of  an 
Aspasia,  the  chastity  of  a  Lucrece,  and  the  intellectual  greatness  of 
a  Cornelia;  she  must  bear  in  mind  the  epigram  of  Bacon,  "A  wife 
must  be  a  young  man's  mistress,  a  middle-aged  man's  companion, 
an  old  man's  nurse." 

In  the  act  of  intercourse  the  woman  must  always  play  the  more 
passive  part;  she  must  be  desired,  rather  than  desire.  Woman's 
modesty  increases  man's  desire.  By  this  coquetry,  permissible  be- 
cause natural,  the  woman  can  bind  the  man  to  herself,  and  can 
give  the  lie  to  the  assertion  that  marriage  is  the  grave  of  love. 
Partial  concealment  of  her  desire  on  the  part  of  the  woman  is  more 
stimulating  to  the  man  than  an  open  manifestation  of  the  sexual 
impulse ;  and  a  certain  amount  of  modest  reluctance  is  more  alluring 
to  him  than  a  plain  invitation.  Plenty  of  room  must  be  left  for 
the  play  of  fancy  and  imagination.  Schiller  makes  Fiesco  say  to 
the  Countess  Julia,  as  he  covers  up  her  bosom,  "  The  senses  must 
be  blind  letter-carriers  only,  and  must  not  be  aware  of  that  which 
nature  and  the  imagination  communicate  each  to  the  other.  The 
best  of  news  is  stale  as  soon  as  it  has  become  the  talk  of  the  town." 


272  THE  SEXUAL  LIFE  OF  WOMAN. 

For  this  reason,  also,  it  is  more  suitable  that  intercourse  should 
take  place,  not  by  day,  consequent  on  the  brutal  prompting  of 
vision,  but  by  night  only,  beneath  the  protecting  veil  of  darkness. 
A  night's  rest,  moreover,  will  serve  to  restore  the  exhausted  nerves, 
and  to  replace  the  expended  secretions.  Less  advisable  is  coitus  in 
the  morning,  on  awaking  from  sleep,  since  the  labors  of  the  day  must 
immediately  thereafter  be  undertaken.  Partially  impotent  men  only, 
who  wake  oip  with  an  erected  penis,  endeavour  to  avail  themselves 
without  delay  of  this  favorable  opportunity,  bearing  in  mind  the 
French  proverb,  "  On  aime  quand  on  peut,  et  non  pas  quand  on 
veut." 

The  French  custom,  in  accordance  with  which  the  married  pair 
sleep  together  in  a  double-bed  is  undesirable  on  several  hygienic 
grounds,  and,  in  the  first  place,  for  the  reason  that  this  continuous 
nocturnal  proximity  is  likely  to  give  rise  to  the  habit  of  indulging 
in  excessively  frequent  acts  of  intercourse.  The  best  and  most  af- 
fectionate of  men  has  neither  disposition  nor  capacity  to  play  the 
part  of  Romeo  every  night,  and  thus  the  value  and  enjoyment  of 
marital  duties  becomes  lessened.  The  fulfilment  of  his  desires  should 
not  be  rendered  quite  so  easy  to  the  husband ;  he  should  always  ap- 
pear the  lover,  one  who  seeks  a  woman's  favours  because  he  longs 
for  her ;  he  should  not  be  the  master,  exacting  an  unquestioned  right. 
For  this  reason,  separate  beds  are  advisable  for  the  married  pair, 
and,  when  possible,  even  separate  bedrooms. 

Among  the  ancients,  Lycurgus,  the  Spartan  law-giver,  regarded 
maternity  as  woman's  principal  attribute,  and  considered  the  sexual 
impulse  to  be  the  means  merely  by  which  healthy  citizens  were  pro- 
vided for  the  state.  In  accordance  with  this  view,  the  sanctity  of 
marriage  was  violated,  and  every  powerful,  handsome,  and  valiant 
Spartan  had  the  right  to  request  the  privilege  of  intercourse  with  the 
wife  of  another,  in  order  to  enrich  that  other's  family  with  his  seed. 
Elderly,  impotent  men.  conducted  well- formed  young  men  into  the 
arms  of  their  own  wives.  The  girls,  like  the  young  men,  went 
through  a  course  of  gymnastic  exercises,  in  order  to  harden  their 
bodies,  and  to  fit  them  for  the  bearing  of  strong  and  healthy  chil- 
dren. No  man  might  marry  before  attaining  the  age  of  thirty,  no 
woman  before  attaining  the  age  of  twenty.  Girls  ripe  for  marriage 
were  assembled  in  a  dark  place,  and  there  the  young  men  chose 
their  brides,  as  chance  might  direct.  The  young  men  were  al- 
lowed to  visit  their  wives  by  night  only,  and  secretly,  in  order  that 
the  vigor  of  the  sexual  impulse  might  be  increased  and  maintained. 

Among  the  Spartans,  it  happened  quite  frequently,  that  a  man 
whose  wife  had  remained  childless,  and  who  believed  himself  to  be 


THE  SEXUAL  EPOCH  OF  THE  MENACME.  273 

at  fault  in  the  matter,  would  beg  one  of  his  fellow-countrymen,  or 
even  a  foreigner,  to  come  to  his  assistance.  It  was  enacted  by  one 
of  Solon's  laws,  to  prevent  a  man  from  neglecting  his  marital  duties, 
that  he  should  have  intercourse  with  his  wife  not  less  than  three 
times  monthly.  According  to  another  of  Solon's  laws,  an  Athenian 
heiress  might  call  upon  her  nearest  relative  for  the  gratification  of 
her  sexual  desires. 

The  bluntest  contrast  to  this  Spartan  simplicity  is  furnished  by 
the  unbridled  lasciviousness  that  prevailed  in  Rome  under  the 
Caesars,  when  women's  sole  desire  was  sexual  enjoyment,  while 
maternity  was  n  state  to  be  avoided.  To  such  an  extreme  was  this 
carried,  that  the  Roman  ladies  of  that  day  preferred  to  marry 
eunuchs,  and  further,  as  Pliny  reports,  hermaphrodites  were  in  great 
request.  Juvenal  writes :  "  There  are  women  who  prize  the  infertile 
embraces  of  base  eunuchs;  thus  they  are  able  to  dispense  with  the 
use  of  abortifacients." 

The  hygiene  of  the  nuptial  night  deserves  from  the  physician 
more  attention  than  it  has  hitherto  generally  received.  He  should 
warn  and  enlighten  the  young  husband,  in  order  that  the  brutality 
with  which  the  act  of  defloration  is  apt  to  be  performed  may  be 
lessened,  and  further  in  order  that  mistakes  in  this  connection,  re- 
sulting from  ignorance  and  likely  to  have  serious  consequences,  may 
be  avoided.  It  is  well  known  that  lacerations  of  the  hymen  and  its 
environment,  and  even  serious  injuries  of  the  genital  organs,  may 
result  from  maladroit  attempts  at  penetration.  The  physician  will 
admonish  the  husband  in  the  words  of  Michelet:  "  Bear  in  mind  in 
this  hour  that  thou  art  an  enemy,  a  tender,  considerate,  and  gentle 


enemy 


The  young  woman  entering  upon  marriage  should  receive  instruc- 
tion from  her  mother  regarding  all  the  sexual  processes  of  copula- 
tion, instruction  at  once  earnest  and  complete.  By  such  enlighten- 
ment, the  young  bride  will  be  spared  much  suffering,  and  a  sudden 
disillusionment  which  might  seriously  affect  the  whole  of  her  future 
life  will  be  avoided ;  complete  ignorance,  on  the  other  hand  may 
lead,  not  merely  to  needless  mental  and  physical  suffering,  but  to 
the  most  tragic  consequences  on  the  bridal  night.  In  one  case  known 
to  me,  the  young  wife,  who  before  marriage  was  utterly  ignorant 
of  the  nature  of  physical  love,  was  so  completely  overwhelmed  in 
her  ideals  by  the  somewhat  energetic  procedure  of  the  bridegroom  as 
soon  as  he  found  himself  alone  with  his  wife,  that  she  fled  from 
her  new  home  then  and  there  in  the  night,  and  by  no  persuasions 
could  be  induced  to  return. 

In  that  decisive  moment  in  which  the  maiden  loses  her  virginity, 
she  must  find  in  her  husband,  not  the  brutal  man  who  forcibly  takes 

18 


274  THE  SEXUAL  LIFE  OF  WOMAN. 

possession  of  her  body,  but  the  chosen  man  of  all,  to  whom  her  love 
can  refuse  nothing. 

"  Delicate  foresight  and  restraint,"  writes  Ribbing,  "  arc  needful 
above  all  at  the  commencement  of  married  life.  The  young  wife, 
coming  to  the  bridal  bed  a  pure  virgin,  is  not,  like  her  husband, 
fully  prepared  for  what  is  to  take  place.  In  all  cases  she  is  some- 
what fearful  of  the  new  experience.  The  first  act  of  intercourse 
involves  for  her  a  certain  amount  of  pain,  and  this  pain  is  not  solely 
physical.  *  *  *  Moreover,  we  must  remember  that  the  entire 
change  in  her  mode  of  life  makes  a  deep  impression  upon  a  woman's 
mind ;  time  and  quiet  are  needed  before  she  can  find  herself  at 
home  in  the  novel  surroundings,  before  she  can  adapt  to  -the  changed 
circumstances  her  moral  and  religious  convictions,  and  before  she 
can  '  think  true  love  acted  simple  modesty  '  (Romeo  and  Juliet,  III, 
2.16).  Impatient  husbands,  through  want  of  knowledge  and  lack 
of  consideration  during  the  honeymoon,  have  often  ruined  the  happi- 
ness of  subsequent  married  life." 

It  happens  often,  unfortunately,  that  the  wife  has  reason  to  com- 
plain of  the  reckless  manner  in  which  her  husband  has  used,  or 
misused,  his  sexual  powers.  Frequently  enough,  on  the  bridal  night, 
the  man  proceeds  with  such  violence  in  his  assault  on  the  virgin 
reproductive  organs  of  his  newly-wedded  wife,  that  we  must  actually 
speak  of  him  as  ravishing  an  ignorant  and  timid  girl.  Later,  when 
the  stimulus  of  novelty  has  passed  away,  the  husband  often  performs 
intercourse  in  a  manner  more  calculated  to  awaken  his  wife's  sexual 
desires,  but  in  seeking  his  own  lordly  gratification  and  obtaining  it 
he  is  still  apt  to  leave  out  of  the  reckoning  the  need  for  effecting 
coitus  in  such  a  way  as  will  give  complete  satisfaction  also  to  his 
wife. 

The  wedding  journey  likewise  deserves  consideration  from  the 
hygienic  standpoint.  Much  is  to  be  said  in  favor  of  such  a  journey, 
inasmuch  as  it  endows  the  necessarily  somewhat  brutal  first  act  of 
intercourse  with  an  aspect  of  romance.  The  removal  to  a  foreign 
country,  to  a  strange  environment,  will  spare  the  chaste  maiden 
much  shame  and  vexation.  On  the  journey,  moreover,  the  young 
couple  are  much  in  each  other's  company,  and  the  process  of  mutual 
adaptation  is  agreeably  favored.  And  yet  this  modern  custom  of 
making  a  wedding  journey  entails  certain  serious  disadvantages. 
The  young  woman  leaves  her  home  and  her  nearest  relatives,  and 
is  in  a  moment  involved  in  the  excitement  of  travel,  an  excitement 
liable  to  increase  to  the  degree  of  morbid  anxiety.  The  fatigues 
of  railway-travel,  of  wandering  about  strange  towns,  of  visits  to 
"museums  and  picture-galleries,  are  apt  to  cause  general  loss  of 
nervous  tone,  and  also  local  hyperaemia  of  the  genital  organs.  In 


THE  SEXUAL  EPOCH  OF  THE  MENACME.  275 

addition,  false  modesty  and  the  prescribed  arrangements  for  the 
journey  may  lead  the  onset  of  menstruation  to  be  ignored  and  the 
customary  rest  at  this  period  to  be  dispensed  with.  Still  more, 
the  possibility  of  the  occurrence  of  conception  and  of  the  commence- 
ment of  pregnancy  is  usually  left  altogether  out  of  the  account. 
Many  an  attack  of  menorrhagia,  of  perimetritis,  and  of  endometritis, 
many  a  miscarriage,  and  many  instances  of  protracted  sterility,  are 
dependent  upon  the  hygienic  mistakes  of  the  wedding  journey,  and 
less,  indeed,  upon  the  abuses  arising  out  of  the  intoxication  of  pas- 
sion, than  upon  the  fatigues  of  excessive  travel  both  by  day  and  by 
night.  The  bride  who  on  her  wedding-day  was  young,  healthy,  and 
full  of  vitality,  not  infrequently  returns  from  the  wedding  journey 
a  sickly  and  debilitated  woman. 

With  regard  to  wedding  journeys  in  relation  to  the  causation  of 
chronic  metritis,  Scansoni  has  expressed  an  authoritative  opinion. 
"After  many  weeks  of  unsatisfied  sexual  desire,  the  young  mar- 
ried pair,  now  freed  from  all  restraint,  give  themselves  up  to 
the  joys  of  love ;  the  intense  sexual  excitement  causes  great  stimula- 
tion and  hyperaemia  of  the  female  sexual  organs;  in  addition,  the 
noxious  influences  of  travel  make  themselves  felt,  and  also  hygienic 
indiscretions  are  perpetrated,  dependent  upon  the  young  wife's 
modesty ;  it  is,  therefore,  by  no  means  to  be  wondered  at  that,  having 
left  home  a  perfectly  healthy  woman,  she  returns  from  her  wedding 
journey  with  the  germs  of  an  illness  from  which  she  never  fully 
recovers,  and  which  is  the  source  of  unending  suffering,  and  more 
particularly  of  a  sterile  marriage." 

Sexual  hygiene  demands  a  certain  moderation  in  the  enjoyment  of 
physical  love,  and  also  a  certain  constancy,  such  as  may  be  ex- 
pected in  a  happy  marriage. 

It  is  not  possible  to  lay  down  a  general  rule  with  regard  to  the 
frequency  of  sexual  intercourse,  notwithstanding  the  earnestness 
with  which  religious  zealots,  physicians,  and  moral  teachers  have 
in  all  ages  endeavored  to  determine  how  often  it  was  proper  for 
a  man  to  cohabit  with  his  wife.  The  rules  that  have  been  prescribed 
by  the  various  authorities  had  in  view,  for  the  most  part,  the  pro- 
tection of  the  wife  from  excessive  demands  on  the  part  of  her  hus- 
band; sometimes,  however,  by  the  establishment  of  a  minimum 
period,  a  certain  amount  of  sexual  gratification  was  secured  to  the 
wife ;  finally,  also,  the  generation  of  a  healthy  posterity  had  to  be 
taken  into  consideration.  Ribbing,  however,  justly  observes :  "  Sex- 
ual intercourse  results  from  a  natural  impulse,  and  he  whose  senses 
are  unimpaired,  and  who  has  learned,  at  the  same  time,  amid  the 
tumult  of  his  sensations,  to  preserve  proper  consideration  for  his 
wife  —  such  a  man  runs  little  danger  of  making  any  mistake.  In 


276  THE  SEXUAL  LIFE  OF  WOMAN. 

opposition  to  the  opinion  of  many,  I  regard  it  as  entirely  right  and 
reasonable  that  husband  and  wife  should  have  intercourse  whenever 
physically  and  mentally  impelled  to  that  act.  Nor  do  I  see  any 
reason  why,  during  the  first  period  in  which  they  are  able  to  enjoy 
without  intermission  the  pleasures  of  sexual  intercourse,  they  should, 
in  accordance  with  any  theory  whatever,  impose  on  themselves 
further  restraints  than  those  demanded  by  care  for  their  physical 
and  mental  health.  The  touchstone  of  marital  hygiene  is  this,  that 
on  the  day  following  intercourse  both  husband  and  wife  should  feel 
perfectly  fresh,  vigorous,  and  lively,  alike  in  body  and  mind  —  even 
more  so,  perhaps,  than  on  other  days.  In  the  absence  of  such  feel- 
ings, we  may  feel  assured  of  the  occurrence  of  sexual  excesses." 
The  same  author  quotes  a  saying  of  Pomcroy's:  "  We  may  quaff 
the  nectar  as  freely  as  we  will  —  nature  herself  mixes  the  draught 
and  holds  the  goblet  to  our  lips ;  if,  however,  we  drink  too  much, 
she  first  dilutes  the  draught  with  water,  later  adds  gall,  and  ulti- 
mately perhaps  deadly  poison." 

The  occupation,  trade,  or  profession,  and  the  nutritive  condition 
and  physical  constitution  of  the  married  pair,  have  an  important 
bearing  on  the  frequency  with  which,  without  detriment  to  health, 
cohabitation  is  permissible.  The  rules  of  the  Hebrew  Talmud  al- 
ready take  these  circumstances  into  account,  ordering  as  they  do 
that  young  and  powerful  men  not  engaged  in  any  regular  occupa- 
tion shall  have  intercourse  with  their  wives  -daily ;  manual  labourers, 
on  the  other  hand,  once  a  week  only ;  whilst  brain- workers,  finally, 
or  those  whose  work  is  extremely  arduous,  should  allow  an  interval 
of  one  or  more  months  to  elapse  between  the  acts  of  intercourse. 
Acton  also  prescribes  that  in  the  case  of  brain-workers  and  of  those 
manual  workers  whose  labours  are  exhausting,  intercourse  must  not 
occur  more  frequently  than  once  every  week  or  ten  days. 

The  married  couple'  should  understand  how  to  impose  on  them- 
selves a  certain  restraint  in  the  matter  of  marital  intercourse,  with- 
out, however,  going  so  far  as  on  altogether  trifling  grounds  to 
refuse  the  husband  access  to  his  wife.  In  this  respect  also,  the 
opinions  that  have  recently  come  to  prevail  concerning  the  rights 
of  women  have  had  an  influence.  W.  Acton  relates  a  case  that 
came  under  his  observation  in  which  the  wife  refused  to  allow  her 
husband  any  voice  in  determining  when  and  how  often  intercourse 
should  take  place ;  the  wife,  she  maintained  without  hesitation,  since 
she  had  to  bear  the  consequences  of  intercourse,  was  fully  justified, 
whenever  she  thought  fit,  in  refusing  her  husband's  embraces. 

The  dangers  to  the  sexual  life  of  woman  which  are  involved  by 
the  modern  woman's  rights  agitation  are  seen  already  in  the  changes 
which  the  emancipation  of  women  in  North  America  has  produced 


THE  SEXUAL  EPOCH  OF  THE  MENACME.  277 

in  the  functions  of  woman  as  wife  and  mother.  In  that  part  of  the 
world,  everything  possible  has  been  done  "  to  transform  "  (to  quote 
the  words  of  a  brilliant  journalist)  "  the  doll  into  an  independent 
existence,  to  enable  the  helpless  woman  to  earn  her  own  sub- 
sistence, and  the  result  of  these  endeavors  has  been  most  strik- 
ing. The  American  woman  has  obtained  the  right  to  enter  every 
profession  and  to  follow  every  kind  of  occupation  which  have 
hitherto  been  reserved  for  men ;  she  is  physician,  lawyer,  merchant, 
professor ;  her  boudoir  has  become  an  office,  often  connected  with 
the  stock  exchange  by  a  private  wire.  Legally,  also,  she  now  pos- 
sesses the  same  rights  as  man ;  in  many  States  she  has  both  the 
suffrage  and  the  right  of  entering  the  house  of  representatives ;  she 
has  fully  emancipated  herself  from  her  former  condition  of  tutelage, 
and  in  her  shrillest  tones  can  cry  to  heaven  '  I  am  free,  I  am  inde- 
pendent, I  am  emancipated,  I  am  myself ! '  And  observe,  as  the 
result  of  all  these  attempts  at  the  conversion  of  woman  into  man, 
that  in  the  matter  of  marriage  also  she  acts  as  if  she  were  no  longer 
woman.  The  American  woman  no  longer  marries ;  perhaps,  indeed, 
because  she  no  longer  has  the  capacity.  So  long  and  so  eagerly  has 
she  given  herself  up  to  masculine  occupations,  that  her  inward 
feminine  nature  has  also  perhaps  undergone  transformation,  so 
that  she  has  become  affected  with  a  kind  of  neutral  lack  of  desire. 
Unquestionably,  the  desire  for  marriage  on  the  part  of  this  modern 
'  emancipated  '  woman  has  vanished  in  the  most  alarming  manner, 
there  is  a  notable  fall  in  the  birth-rate,  and  the  indigenous  (white) 
population  actually  threatens  to  disappear." 

The  wife  acts  wisely,  not  on  hygienic  grounds  alone,  in  not 
always  acceding  at  once  and  unconditionally  to  her  husband's  de- 
mand for  the  repetition  of  intercourse.  Her  modest  reluctance  en- 
hances her  desirability  in  the  eyes  of  her  amorous  husband.  Thus, 
Shakespeare  makes  Posthumus  exclaim  (Cymbeline,  Act  II.,  Sc.  5, 

1.9): 

"  Me  of  my  lawful  pleasure  she  restrained 
And  prey'd  me  oft  forbearance ;  did  it  with 
A  pudency  so  rosy  the  sweet  view  on't 
Might  well  have  warmed  Old  Saturn." 

Especially  justified  is  such  refusal  when  coitus  has  been  already  once 
or  twice  performed,  or  when  the  consumption  of  alcoholic  beverages 
has  made  the  husband  unduly  lustful.  On  the  other  hand,  the  re- 
fusal of  intercourse  when  demanded  by  the  husband  should  never 
depend  upon  baseless  feminine  caprice,  or  upon  the  now  so  fre- 
quently asserted  "  rights  of  women." 

Experience  has  long  ago  established  as  a  fact  that  unduly  fre- 
quent satisfaction  of  the  sexual  impulse  entails  serious  consequences 
to  the  health  of  the  individual.  And  in  the  case  of  the  wife  these 


278  THE  SEXUAL  LIFE  OF  WOMAN. 

consequences  may  be  especially  disastrous  when  intercourse  is  in- 
dulged in  recklessly  during  menstruation,  during  all  stages  of  preg- 
'  nancy,  and  even  during  the  puerperium.  "  Incontinence  during 
menstruation  leads  to  serious  circulatory  disturbances  and  to  the 
consequences  of  these  disturbances;  during  pregnancy  it  is  likely 
to  give  rise  to  miscarriage ;  during  the  puerperium,  to  congestions 
and  inflammations.  Should  conception  occur  as  a  result  of  inter- 
course during  the  lying-in  period  (and  this  may  happen  very  shortly 
after  childbirth),  abortion,  and  even  more  serious  consequences,  are 
likely  to  ensue.  By  intercourse  during  lactation,  the  premature 
recurrence  of  the  menstrual  flow  is  induced,  and  the  gradual  re- 
version of  the  reproductive  apparatus  to  the  condition  in  which  it 
was  before  pregnancy  (the  process  of  involution)  is  hindered  ;  more- 
over, the  secretion  of  milk  is  diminished  or  even  entirely  suppressed." 
In  these  terms  Hegar  depicts  the  consequences  of  premature  resump- 
tion of  marital  intercourse,  taking  perhaps  a  somewhat  extreme  view 
of  the  matter. 

Nevertheless,  this  author  is  undoubtedly  right  in  declaring  that 
one  of  the  principal  disadvantages  to  a  woman  of  excessively  fre- 
quent sexual  intercourse  is  that  pregnancy  occurs  too  often.  It 
is  astonishing  to  observe  the  number  of  full-term  deliveries  and 
miscarriages  that  a  woman  will  experience  within  a  comparatively 
short  period  of  time,  as  is  seen  too  frequently  among  the  labouring 
classes  and  more  especially  among  factory  workers.  "  If  we  assume 
the  ordinary  mortality  of  childbed  to  be  6  per  mille,  a  woman  who 
in  the  course  of  15  years  undergoes  labour  (at  full  term  or  pre- 
maturely) 16  times,  runs  a  risk  of  death  to  be  expressed  by  the 
ratio  of  6X16  =  96  per  mille;  that  is  to  say,  on  the  average,  of 
1,000  women  who  become  pregnant  as  often  as  this,  nearly  i  in  10 
will  die  in  childbed." 

Young  men  who  have  previously  suffered  from  gonorrhoea  and 
who  wish  to  marry,  must,  unless  they  wish  to  cause  unspeakable 
misery,  undergo  an  exact  and  thorough  examination ;  not  only  must 
the  physician  inquire  as  to  the  presence  of  certain  symptoms,  such 
as  smarting  during  micturition,  adhesion  of  the  lips  of  the  urethral 
meatus,  "  clap-threads  "  in  the  urine,  etc.,  but  during  a  considerable 
period  of  time  repeated  microscopical  examinations  of  the  urine  must 
be  undertaken,  and  the  filaments,  if  present,  must  be  examined  for 
gonococci.  The  physician  will  also  have  to  determine  whether  any 
vestiges  remain  of  epididymitis,  and  whether  the  quality  of  the 
semen  'has  been  impaired  by  the  attack  of  gonorrhoea.  Unfortu- 
nately, it  is  not  yet  within  our  power  absolutely  to  forbid  marriage 
to  a  man  exhibiting  all  the  symptoms  of  chronic  gonorrhoea ;  but  it 
is  the  duty  of  the  physician  to  explain  to  such  a  man  the  scientific 


THE  SEXUAL  EPOCH  OF  THE  MENACME.  279 

views  regarding  this  matter  that  now  prevail,  in  order  to  furnish 
him  with  the  grounds  for  a  decision. 

It  is  not  possible,  when  discussing  the  hygiene  of  married  life, 
to  preserve  silence  respecting  the  extremely  pressing  question  of 
the  use  of  measures  for  the  prevention  of  conception,  for  in  recent 
years  their  use  has  become  extraordinarily  general,  chiefly,  indeed, 
in  the  upper  and  middle  classes  of  society,  but  to  some  extent  also 
among  the  working-class  population.  Although  we  devote  a  special 
chapter  to  this  topic,  we  must  here  express  the  opinion  that,  except 
in  certain  instances  in  which  their  employment  can  be  justified  on 
carefully  weighed  and  well-established  medical  grounds,  the  use  of 
any  mechanical  or  chemical  means  for  the  prevention  of  conception 
must  be  discountenanced  as  injurious  to  health.  The  wife  who 
wishes  to  preserve  her  psychical  purity  and  moral  chastity,  which  is 
not  only  possible  in  marriage  but  also  greatly  to  be  desired,  must 
not  concern  herself  much  with  the  technique  of  the  sexual  life,  but 
must  give  herself  up  to  sexual  enjoyment  only  as  the  result  of  a 
delicate  and  immediate  bodily  and  mental  desire.  Not  only  for 
reasons  of  national  economy  regarding  the  means  of  providing  for 
the  family,  but  also  for  well-grounded  personal  reasons  regarding 
the  wife's  health,  must  the  latter  be  spared  an  unduly  rapid  succes- 
sion of  pregnancies  and  confinements.  And  this  should  be  effected 
by  a  certain  degree  of  continence  and  by  the  observation  of  exten- 
sive periods  of  sexual  quiescence. 

To  preserve  a  woman's  health  during  the  acme  of  her  sexual 
activity,  a  careful  general  hygiene  is  an  important  requisite.  The 
dwelling  should  be  dry  and  roomy;  above  all  the  bedroom  should 
not  be  too  small,  neither  damp  nor  dark,  and  it  should  be  well  venti- 
lated. The  wife's  occupations  should  be  so  arranged  as  to  afford  a 
suitable  alternation  of  activity  and  repose,  and  there  should  be  as  little 
night  work  as  possible.  Certain  occupations  are  especially  potent  in 
the  causation  of  the  diseases  peculiar  to  women,  principally,  for  the 
reason  that  they  do  not  permit  of  the  requisite  repose  during  men- 
struation. Thus,  washerwomen,  vocalists,  and  sewing-machine  oper- 
atives, suffer  with  especial  frequency  from  diseases  of  the  genital 
organs. 

Great  care  in  the  cleansing  of  the  genital  organs  is  indispensable 
in  the  case  of  women ;  the  vulva  and  its  environment  should  be  fre- 
quently and  carefully  washed;  and  an  occasional  vaginal  injection 
is  advantageous.  As  regards  the  last-named  measure,  however,  we 
must  point  out  that  it  is  possible  to  err  by  excess  as  well  as  by 
defect,  and  that  a  daily  vaginal  douche  can  by  no  means  be  regarded 
as  a  necessary  part  of  the  hygiene  of  the  reproductive  organs.  For 
recent  researches  have  shown,  on  the  one  hand,  that  the  vagina  con- 


280  THE  SEXUAL  LIFE  OF  WOMAN. 

stitutes  a  natural  mechanism  for  the  destruction  of  pathogenic  organ- 
isms, and  on  the  other  hand,  that  complete  disinfection  of  the  vagina 
is  extremely  difficult  to  effect.  Inflammations  of  the  vulva,  which 
are  somewhat  frequent  in  consequence  of  excessive  perspiration  and 
undue  discharge  from  the  genital  canal,  demand  careful  cleansing 
with  soap  and  water  and  the  use  of  a  soft  brush.  The  addition  to 
the  water  of  lysol  (in  the  proportion  of  l/±  to  l/>  per  cent.)  is 
advantageous.  A  general  bath  or  a  local  sitz  bath,  the  water  being 
moderately  warm  (95°-99°  F. ;  35°— 37°  C.),  may  be  recommended 
on  grounds  of  beauty  as  well  as  of  health,  and  should  be  taken  at 
least  once  a  week. 

The  regular  use  of  lukewarm  sitz  baths  is  a  most  valuable  hygienic 
measure  for  the  prevention  of  various  general  or  local  disturbances 
consequent  upon  increased  flow  of  blood  to  the  genital  organs. 
These  local  baths  are  best  taken  at  a  temperature  of  95°  F.  (35°  C.), 
and  should  last  twenty  minutes;  they  should  be  taken  just  before 
going  to  bed,  and  while  sitting  in  the  hip  bath  the  skin  of  the  abdo- 
men and  of  the  lower  part  of  the  back  should  be  rubbed  with  the 
hand  encased  in  a  friction-glove.  The  bather  on  leaving  the  bath 
should  get  straight  into  bed,  and  should  dry  herself  beneath  the  bed- 
clothes, rubbing  the  skin  till  it  glows.  Such  sitz  baths  serve  also  to 
keep  the  external  genitals  clean,  and  to  guard  against  infection.  For 
vaginal  douching,  water  sterilized  by  boiling  should  be  employed, 
and  where  any  catarrh  of  the  vaginal  mucous  membrane  is  present, 
some  alum,  permanganate  of  potassium,  or  boric  acid  may  be  added 
with  advantage ;  the  pressure  of  water,  when  a  vaginal  douche  is 
given,  should  never  be  high,  the  reservoir  of  the  irrigator  being 
raised  not  more  than  twenty  inches  above  the  outlet  of  the  nozzle ; 
as  a  rule  the  water  should  be  lukewarm ;  the  patient  should  be  in 
the  recumbent  posture.  The  reservoir  of  the  irrigator  and  the 
intravaginal  nozzle  are  most  suitably  made  of  glass,  to  insure 
cleanliness;  the  nozzle  should  not  be  thrust  too  far  in,  two  inches 
being  quite  sufficient.  After  the  use  of  the  douche,  the  woman 
should  remain  ten  or  fifteen  minutes  in  the  recumbent  posture. 

In  addition  to  the  hygenic  employment  of  such  full  baths  and 
local  baths,  a  number  of  mineral  baths  have  important  therapeutic 
applications  in  cases  of  disease  of  the  female  genital  organs,  the 
traditional  value  of  such  baths  having  been  scientifically  endorsed  by 
the  modern  science  of  balneo-therapeutics.  By  means  of  suitably 
selected  mineral  water  baths,  a  powerful  derivative  stimulus  may  be 
given  to  the  skin,  and  the  affectted  reproductive  organs  may  thus  be 
beneficially  influenced.  Further,  in  acute  inflammatory  conditions 
or  hyperremia  of  the  uterus  or  its  annexa,  these  baths  have  an  an- 
tiphlogistic influence;  on  the  other  hand,  when  intrapelvic  exuda- 


THE  SEXUAL  EPOCH  OF  THE  MENACME.  281 

tions  have  formed,  the  baths  promote  the  absorption  of  these  in- 
flammatory products ;  again,  in  congestive  states  of  the  female 
genital  organs,  with  relaxation,  thickening,  and  hypersecretion  of 
the  genital  mucous  membrane,  the  baths  have  an  astringent  and 
tonic  influence  on  the  tissues;  finally,  they  have  a  favorable  effect 
on  the  inner vation  and  nutrition,  not  only  of  the  reproductive  appa- 
ratus, but  of  the  entire  organism.  It  is  easy  to  understand  why 
women  during  the  menacme  are  frequent  visitors  to  spas. 

At  this  period  of  life,  and  especially  in  women  who  lead  luxurious 
"  society  "  lives,  the  thoughts  tend  strongly  in  the  sexual  direction ; 
to  avoid  this,  and  to  prevent  the  ever  more  and  more  frequent 
breaches  of  marital  fidelity,  the  best  means  are  the  practice  of  vigor- 
ous bodily  exercises,  and  active  employment,  either  in  household  af- 
fairs or  in  intellectual  occupations.  Cold  sponging  of  the  body  or 
cold  full  baths  will  also  be  found  an  excellent  measure  for  the  pre- 
vention of  sexual  excess.  In  such  cases  also  the  diet  should  be 
limited,  strong  and  stimulating  food  should  be  avoided,  but  little 
butcher's  meat  should  be  taken,  whilst  green  vegetables  and  raw 
and  cooked  fruits  should  be  liberally  consumed ;  at  the  same  time, 
all  alcoholic  beverages  must  be  rigidly  prohibited.  Moreover,  care 
must  be  taken  that  during  the  night  there  should  be  no  undue  physi- 
cal stimulation  in  consequence  of  excessively  warm  and  soft  bedding ; 
hair  mattresses  are  to  be  preferred  to  feather  beds,  with  light  down 
quilts  for  a  covering.  Finally,  no  stimulation  of  an  erotic  character 
should  be  offered  to  the  imagination,  and  for  this  reason  equivocal 
literature  and  lascivious  dramatic  representations  must  be  avoided. 
By  a  sufficiency  of  occupation,  regular,  interesting,  and  demanding 
a  considerable  expenditure  of  physical  energy,  a  woman  may  be 
enabled  to  a  great  extent  to  escape  the  inconvenience  and  distress 
attendant  on  entire  or  partial  lack  of  gratification  of  the  sexual 
impulse. 

It  cannot  be  disputed  that  a  certain  and  moderate  amount  of 
sexual  gratification  is  requisite  for  the  perfect  maintenance  of  physi- 
cal health  in  woman,  and  that  the  absence  of  this  gratification,  or 
the  gratification  of  the  impulse  in  an  abnormal  or  incomplete  man- 
ner, entails  disturbance  of  alike  the  mental  and  the  physical  equi- 
librium ;  but,  on  the  other  hand,  the  deleterious  consequences  of 
sexual  abstinence  have  been  greatly  exaggerated  by  many  writers  — 
both  by  physicians  and  social  economists.  Owing  to  the  fact  that 
to  the  cultivated  woman  sexual  gratification  is  possible  only  in  the 
married  state,  whilst  social  conditions  render  marriage  impossible 
to  many  women  greatly  in  need  of  such  gratification  ;  in  consequence, 
also,  of  the  modern  and  ever  more  widely  diffused  practice  by  hus- 
bands of  coitus  interruptus  altogether  regardless  of  the  woman's 
need  for  complete  sexual  gratification  —  there  arise  in  women  nu- 


282  THE  SEXUAL  LIFE  OF  WOMAN. 

merous  local  disorders  and  nervous  disturbances,  hysteria  and  even 
insanity  being  results  by  no  means  infrequent.  The  significance 
of  ungratified  sexual  impulse  in  the  pathogenesis  of  nervous  dis- 
orders has  been  established  by  von  Krafft-Ebing,  who  points  out 
that  in  unmarried  women  insanity  most  frequently  occurs  between 
the  ages  of  twenty-five  and  thirty-five  years,  during  the  decade, 
that  is  to  say,  in  which  youthful  bloom  and  the  hopes  of  marriage 
simultaneously  disappear;  whereas  in  the  male  sex  the  greatest  in- 
cidence of  insanity  is  between  the  ages  of  thirty-five  and  fifty  years, 
the  period  of  life  in  which  the  struggle  for  existence  is  fiercest. 

Hegar,  on  the  other  hand,  is  a  firm  opponent  of  the  view  that 
the  favourable  influence  of  marriage  is  overrated.  According  to 
this  author,  the  favourable  effect  of  marriage  in  respect  of  mental 
disorders  is  to  be  found,  not  in  the  gratification  of  the  sexual  im- 
pulse, but  in  the  ethical  factors  of  marriage.  Statistics  show  that 
even  in  the  favourable  circumstances  of  marriage,  sexual  gratification 
has  in  women  an  unfavourable  influence,  inasmuch  as  the  proportion 
of  sufferers  from  mental  disorders  is  higher  among  married  women 
than  it  is  among  married  men.  A  study  of  the  mental  disorders 
which  in  women  are  especially  associated  with  the  process  of  re- 
production (puerperal  mania)  confirms  this  impression.  He  gar 
insists  that  he  has  never  seen  nymphomania  arise  in  women  in  con- 
sequence of  forcible  repression  of  the  sexual  impulse;  but  that  he 
has  not  infrequently  seen  this  disorder  result  from  unnatural  ex- 
cesses or  from  long-continued  sexual  irritation,  especially  in  heredi- 
tarily predisposed  persons.  Such  unnatural  stimulation  of  the  female 
is  not  infrequently  practiced  by  the  male — by  the  lover  and  even 
by  the  husband  —  it  may  be  because  he  himself  derives  pleas- 
ure from  such  perverted  practices,  and  wishes  to  obtain  sexual 
gratification  without  the  risk  of  impregnation,  or  because  he 
is  himself  incompetent  for  normal  complete  intercourse.  Hegar 
is  further  of  opinion  that  in  the  causation  of  hysteria  and  also 
in  that  of  chlorosis  the  repression  of  the  sexual  impulse  plays 
a  quite  subordinate  role.  And  he  regards  as  pure  fable  the  be- 
lief that  continence  in  women  is  liable  to  lead  to  the  formation 
of  mammary,  uterine,  or  ovarian  tumors.  He  would  more 
readily  incline  to  the  contrary  opinion;  the  reproductive  proc- 
ess being  in  this  respect  distinctly  disadvantageous  to  the  female 
sex.  The  unfavorable  influence  of  the  reproductive  process  is 
shown  most  clearly  in  the  case  of  carcinoma  of  the  uterus;  the 
majority  of  the  patients  suffering  from  this  disease  are  either  mar- 
ried or  widowed,  and  many  of  them  have  given  birth  to  a  large 
number  of  children.  "  Gratification  of  the  sexual  impulse,  and  more 
particularly  the  reproductive  process,  give  rise  in  women  to  the 


THE  SEXUAL  EPOCH  OF  THE  MENACME.  283 

formation  and  growth  of  tumors,  cause  numerous  mechanical  dis- 
turbances, and  open  the  way  to  infection  with  various  pathogenic 
organisms." 

He  gar  considers  that  there  is  hygienic  justification  for  the  limita- 
tion of  the  number  of  children  to  which  a  woman  gives  birth. 
The  most  suitable  age  for  motherhood  lies  in  his  opinion  between 
the  ages  of  twenty  and  forty  years.  Childbirth  in  women  younger 
or  older  than  this  entails  too  much  danger  both  to  mother  and  child. 
At  least  two  and  a  half  years  ought  to  elapse  between  two  successive 
births ;  and  these  figures  give  us  eight  as  the  maximum  family. 
If  we  assume  that  the  duration  of  pregnancy  is  nine  months,  and 
that  of  lactation  nine  to  twelve  months  (or  in  cases  in  which  the 
mother  does  not  nurse  her  own  infant,  that  a  like  period  must  be 
devoted  to  the  careful  supervision  of  the  wet-nurse  or  of  the  methods 
of  artificial  feeding),  we  cannot  consider  it  unreasonable  to  devote 
a  further  period  of  from  six  to  nine  months  to  the  complete  re- 
establishment  of  the  woman's  health.  "  Moreover,  woman  does  not 
exist  solely  for  the  purpose  of  subserving  during  two  decades  of 
her  life  the  processes  of  reproduction.  And  to  permit  the  maximum 
number  of  children  to  be  as  great  as  eight,  we  must  presuppose 
that  the  woman  is  in  perfect  health,  and  that  she  lives  in  a  perfectly 
healthy  environment.  Any  illness  or  infirmity  which  renders  the 
duties  of  housekeeping  and  the  rearing  of  the  existing  family  unduly 
difficult,  indicates  the  need  for  a  further  limitation  of  childbe.aring. 
And  if  the  reproductive  function  is  to  be  rationally  controlled,  we 
must  above  all  attend  to  the  age  and  the  health  of  the  parents. 
Occupation,*  habitation,  and  general  environment  have  also  to  be 
considered.  The  correct  ideal  is  indeed  not  difficult  to  discover." 

Hegar  concludes  that  strict  moderation  and  even  absolute  con- 
tinence in  sexual  matters  are  often,  and  for  long  periods  of  time, 
a  pressing  duty.  "  The  numerous  and  various  disasters  which  are 
brought  upon  the  world  by  unbridled  and  unregulated  sexual 
passion  can  be  prevented  only  by  enlightenment,  moderation,  and 
continence.  If  marriage  were  postponed  until  the  attainment  of 
complete  physical  maturity,  in  women  till  the  age  of  20,  in  men  till 
the  age  of  25,  while  at  the  same  time  procreation  were  no  longer 
undertaken  by  women  above  the  age  of  40  or  by  men  above  the 
age  of  45  to  50  years ;  if,  again,  between  successive  pregnancies 
a  sufficient  pause  for  the  woman's  recuperation  were  insisted  upon, 
and  intercurrent  illnesses  and  states  of  debility  were  taken  into 
account ;  and  if,  finally,  sickly  individuals,  those  hereditarily  pre- 
disposed to  disease,  and  those  in  any  way  below  par  either  mentally 
or  physically,  were  more  than  heretofore  prevented  from  marrying; 
then  the  increase  of  population,  which  in  Germany  is  unquestionably 


284  THE  SEXUAL  LIFE  OF  WOMAN. 

too  rapid,  would  to  some  extent  be  checked.  Thoroughgoing 
regulation  of  the  reproductive  process  will  not,  however,  be  thus 
attained  without  the  adoption  of  a  method  of  selection  too  rigorous 
for  present-day  notions ;  and  for  a  further  advance  we  must  in 
the  meantime  depend  upon  moderation  and  continence."  As  regards 
the  modern  demand  of  the  ''  right  to  love/'  the  same  experienced 
gynecologist  writes :  "  Whoever  preaches  to  mankind  the  doctrine 
that  '  a  man  sins  against  his  own  personality  if  he  neglects  to  exer- 
cise every  limb  he  possesses,  and  if  he  denies  himself  the  gratification 
of  every  natural  impulse/  or  the  doctrine  that  '  it  is  the  duty  of 
every  human  being  to  gratify  all  his  natural  impulses,  since  these 
are  most  intimately  inter-connected  with  his  personality  —  are  indeed 
his  personality  itself ;'  such  a  preacher  does  harm  to  his  kind.  Such 
rights  and  such  duties  are  chimerical  for  this  reason  if  for  no  other, 
because  two  persons  are  necessary  in  the  case  of  sexual  gratification, 
and  sometimes  —  though  not  as  often  as  might  be  wished — Hans 
fails  to  find  his  Crete,  without  any  consequent  loss  to  society  at 
large." 

An  especially  important  chapter  in  the  history  of  woman  at  this 
period  of  life  relates  to  the  dietetics  of  pregnancy  and  parturition, 
and  to  the  regulations  to  be  observed  for  the  maintenance  of 
health  at  this  time  and  in  connection  with  the  processes  of  preg- 
nancy, parturition,  puerperal  involution  of  the  uterus,  and  lactation. 
This  subject  cannot  now  however  be  considered  at  length,  and  for 
our  present  purposes  it  is  sufficient  to  point  out  how  important 
it  is  alike  for  mother  and  child,  alike  for  family  and  society,  that 
the  ever  more  and  more  widely  and  generally  diffused  practice  of  the 
artificial  feeding  of  infants  should  be  abandoned,  and  that  there 
should  be  a  return  to  the  natural  method  according  to  which  each 
mother  nurses  her  own  infant.  The  prevailing  custom  costs  every 
year  thousands  of  mothers  their  health,  and  thousands  of  children 
their  lives. 

COPULATION  AND  CONCEPTION. 
Copulation. 

The  reproduction  of  the  species  is  effected  by  means  of  an  act  of 
copulation  on  the  part  of  a  male  and  a  female  individual,  both 
of  whom  must  have  attained  complete  sexual  development.  In 
all  the  sequence  of  reproductive  processes  it  is  copulation  alone 
that  is  a  voluntary  act.  all  the  other  processes  being  independent 
of  the  will  and  even  of  consciousness. 

A  characteristic  difference  between  man  and  the  lower  animals 
lies  in  the  fact  that  in  the  human  species  sexual  pleasure  and  the 
act  of  copulation  may  occur  at  any  season  of  the  year;  and  a 


THE  SEXUAL  EPOCH  OF  THE  MENACME.  285 

further  characteristic  difference  may  perhaps  be  found  in  the  fact 
that  in  the  great  majority  of  individuals  of  the  human  species  the 
psychical  process  of  "  love  "  plays  a  determinative  part.  Voltaire 
pointed  out  that  to  man  alone  among  animals  are  known  the  em- 
brace and  the  joy  of  the  kiss. 

The  significance  of  the  kiss  is  depicted  by  Grillparser  in  the  fol- 
lowing verses: 

Auf  die  Hande  kiisst  die  Achtung, 
Auf  die  Wangen  Wohlgefallen, 
Seelige  Liebe  auf  den  Mund. 
Auf  den  Nacken  das  Verlangen; 
Uberall  sonsthin  Raserei.* 

In  this  act  of  conjugation  between  two  individuals  of  the  same 
species,  differentiated  each  from  the  other  by  the  characteristics  of 
sex,  the  active,  provocative  role  is  allotted  to  the  male,  the  passive, 
receptive  role,  to  the  female.  The  modest  and  coy  reluctance  char- 
acteristic alike  of  the  maiden  and  of  the  wife,  promote  an  increase 
of  sexual  excitement  in  the  opposite  sex,  and  this  not  only  in  a 
man  of  purely  sensual  character,  whose  vanity  is  stimulated  by  his 
being  the  chosen  one  among  many  —  a  circumstance  which,  in  view 
of  the  great  dependence  of  the  sexual  act  upon  psychical  processes 
and  imaginative  influences,  is  by  no  means  devoid  of  importance. 
The  woman's  coy  reluctance  must  be  overcome  by  means  of  a 
tender  strategy  before  she  is  willing  to  grant  the  final  possession  of 
her  body ;  and  the  act  of  copulation  forms  at  the  same  time  the  con- 
clusion of  the  physical  and  mental  yearnings  of  the  lover,  and  the 
commencement  of  the  new-coming  being.  There  is  thus  a  physio- 
logical reason  for  the  advice  given  by  the  celebrated  surgeon,  Am- 
broise  Pare,  that  a  man,  before  completing  coitus,  should  employ 
some  of  the  delicate  and  sensually  stimulating  manipulations  of  the 
earlier  stages  of  courtship,  for,  he  writes,  "  aucunes  femmes  ne 
sont  pas  si  promptes  a  ce  jeu  que  les  hommes." 

The  potency  for  intercourse  of  the  sexually  mature  man,  his 
capacity  for  the  introduction  of  the  erect  penis  during  the  act  of 
copulation,  is  dependent  on  the  fact  that  sexual  excitement  gives 
rise  to  a  sufficient  stimulus  which,  acting  on  the  erection  centre 
(and  presuming  that  the  centre  and  its  afferent  and  efferent  tracts 
are  normal),  leads  to  an  increased  flow  of  arterial  blood  to  the  penis 

*  Respect  kisses  the  hand, 
Affection  kisses  the  cheek, 
Spiritual  love  kisses  the  mouth. 
Desire  the   neck : 
Amatory  frenzy  kisses  the  whole  body. 


286  THE  SEXUAL  LIFE  OF 

and  a  diminished  outflow  through  the  veins  of  that  organ,  and 
consequently  to  its  erection.  The  cerebrum  is  the  organ  in  which 
the  sensation  of  libido  sexualis,  of  sexual  excitement,  has  its  seat ; 
with  this  higher  centre  is  connected  by  means  of  intercentral  nerve 
tracts  a  lower,  mechanical,  reflex  centre,  situated  in  the  lumbar  en- 
largement of  the  spinal  cord,  and  presiding  over  the  performance 
of  the  act  of  copulation ;  it  is  moreover  provable  that  nerve  fibres 
proceed  from  the  spinal  cord  direct  to  the  blood  vessels  of  the 
erectile  tissue,  by  means  of  which  the  calibre  of  these  vessels  can 
be  lessened  or  their  extensibility  diminished.  The  relation  of  the 
erector  nerves  (nervi  erigentes)  to  the  penis  is  by  many  physiologists 
compared  to  the  relation  of  the  vagus  nerve  to  the  heart.  In  the 
quiescent  state  the  small  arteries  of  the  penis  and  perhaps  also  the 
cavernous  spaces  of  that  organ  are  in  a  state  of  mean  contraction, 
so  that  they  offer  a  considerable  resistance  to  the  passage  of  the 
blood  current.  When  now  the  nervi  erigentes  are  excited  to  activity, 
the  hitherto  tonically  contracted  vessels  of  the  penis  undergo,  ac- 
cording to  the  school  of  physiologists  just  mentioned,  relaxation,  so 
that  they  dilate  under  the  pressure  of  the  blood  within  their  walls, 
and,  the  previous  resistance  to  the  flow  being  now  removed,  the 
blood  pours  freely  into  the  cavernous  spaces  of  the  penis,  and 
distends  these  to  the  uttermost.  In  this  manner  erection  is  effected, 
rendering  possible  the  insertion  of  the  penis  into  the  genital  passage 
of  the  female ;  with  the  culmination  of  the  sexual  act,  the  semen  is 
ejaculated,  the  muscles  of  the  prostate  and  the  membranous  portion 
of  the  urethra  together  with  the  ischiocavernosus  and  bulbocaver- 
nosus  muscles,  all  acting  strongly  and  simultaneously. 

By  the  contraction  of  the  muscular  apparatus  just  described,  the 
penis  is  constricted  in  the  neighborhood  of  the  pubic  symphysis, 
and  this  further  hinders  the  outflow  of  the  blood  from  the  corpora 
cavernosa,  increasing  the  intensity  of  the  state  of  erection  of  the 
penis.  Should  the  relaxation  of  the  corpora  cavernosa,  dependent 
upon  the  stimulation  of  the  nervi  erigentes,  be  incomplete,  it  is  not 
possible  for  sufficient  blood  to  pass  into  the^cavernous  spaces  to 
exercise  considerable  pressure  upon  the  efferent  veins,  and  thus 
complete  erection  fails  to  occur.  If,  again,  the  contraction  of  the 
muscular  apparatus  at  the  root  of  the  penis  is  insufficiently  vigorous, 
complete  erection  likewise  fails  to  occur;  the  organ  becomes  semi- 
erect  only,  or  erect  for  a  period  too  short  to  permit  of  the  com- 
pletion of  intercourse. 

Since,  physiologically  speaking,  conception  is  the  purpose  with 
which  copulation  is  effected,  the  ejaculation  of  the  semen  must 
be  regarded  as  the  principal  object  of  that  act;  now  in  normal 
conditions,  ejaculation  takes  place  only  when  the  penis  is  fully  erect. 


THE  SEXUAL  EPOCH  OF  THE  MENACME.  287 

Associated  with  the  erection  of  the  corpora  cavernosa  is  a  swelling 
of  the  caput  gallinaginis,  whereby  the  orifices  of  the  ejaculatory 
ducts  are  directed  forwards  toward  the  membranous  portion  of  the 
urethra,  and  at  the  same  time  the  backward  passage  to  the  bladder 
is  cut  off.  By  this  mechanism,  the  urethra,  which  usually  serves 
as  the  canal  for  the  outflow  of  urine,  is  made  for  the  time  being 
solely  subservient  to  the  purposes  of  the  sexual  act.  That  the  outlet 
from  the  bladder  is  obstructed  by  the'  swollen  caput  gallinaginis 
When  the  penis  is  erect,  is  shown  by  the  familiar  fact  that  a  man 
whose  penis  is  erect  cannot  pass  water,  although  the  way  is  freely 
open  for  the  ejaculation  of  the  semen. 

Before  ejaculation  begins,  the  urethral  glands  already  begin  to 
secrete;  and  when  erection  is  powerful  and  prolonged,  this  secre- 
tion often  makes  its  appearance  at  the  urethral  orifice  in  the  form 
of  drops  of  a  clear  somewhat  tenacious  fluid.  Ultsmann  considers 
that  the  function  of  this  secretion  is  probably  to  moisten  the  walls 
of  the  urethra,  over  which  the  acid  urinary  secretion  is  continually 
flowing,  with  a  protective  alkaline  fluid,  and  thus  to  prepare  the 
canal  for  the  passage  of  the  semen.  An  analogy  may  be  found  in 
the  secretion  of  the  cervical  glands  of  the  uterus  in  the  female,  for 
this  secretion  has  been  found  to  enhance  the  activity  of  the  move- 
ments of  the  spermatozoa.  If  now  during  copulation  the  moment 
of  ejaculation  begins,  the  male  experiences  at  the  same  time  a  sense 
of  voluptuous  pleasure  and  a  feeling  of  muscular  spasm  in  the 
perineal  region,  and  this  indicates  the  commencing  evacuation  of 
the  contents  of  the  seminal  vesicles  through  the  ejaculatory  ducts. 
Simultaneously,  the  secretion  of  the  prostate  is  poured  into  the 
urethra.  The  semen  now  gradually  passes  out  through  the  narrow 
ejaculatory  ducts,  and,  since  in  consequence  of  the  swelling  of  the 
caput  gallinaginis,  it  cannot  pass  backwards  towards  the  bladder, 
it  runs  forwards,  and  accumulates  in  the  bulb  of  the  urethra,  the 
physiological  excavation  of  that  tube.  As  soon  as  a  considerable 
quantity  of  the  semen  has  collected  in  this  situation,  so  that  the 
bulb  of  the  urethra  becomes  distended,  reflex  contractions  of  the 
bulbocavernosus  muscles  ensue,  by  means  of  which  the  seminal 
fluid  is  forced  out  of  the  urethral  orifice.  In  cases  in  which  this 
muscular  apparatus  does  not  function  properly,  as  in  the  paralytic 
form  of  impotence,  the  semen  during  ejaculation  is  not  ejected  in  a 
forcible  jet,  but  rather  flows  slowly,  as  from  a  lax  tube  partially 
filled  with  fluid,  from  the  urethral  orifice. 

We  are  indebted  to  Roubaud  for  a  classical  description  of  the 
phenomena  of  copulation,  and  this  description  is  here  appended. 
Tt  runs  as  follows :  "As  soon  as  the  penis  enters  the  vaginal  vesti- 
bule, it  first  of  all  pushes  against  the  glans  clitoridis,  which  yields 


288  THE  SEXUAL  LIFE  OF  WOMAN. 

and  bends  before  it.  After  this  preliminary  stimulation  of  the  two 
chief  centres  of  sexual  sensibility,  the  glans  penis  glides  over  the 
inner  surfaces  of  the  two  vaginal  bulbs ;  the  collum  and  the  body 
of  the  penis  are  then  grasped  between  the  projecting  surfaces  of 
the  vaginal  bulbs,  but  the  glans  penis  itself,  which  has  passed 
further  onward,  is  now  in  contact  with  the  fine  and  delicate  surface 
of  the  vaginal  mucous  membrane,  which  membrane  itself,  owing  to 
the  presence  of  erectile  tissue  between  its  layers,  is  now  in  an  elastic, 
resilient  condition.  This  elasticity,  which  enables  the  vagina  to  adapt 
itself  to  the  size  of  the  penis,  increases  at  once  the  turgescence  and 
the  sensibility  of  the  clitoris,  inasmuch  as  the  blood  that  is  driven 
out  of  the  vessels  of  the  vaginal  wall  passes  thence  to  those  of  the 
vaginal  bulbs  and  the  clitoris.  On  the  other  hand,  the  turgescence 
and  the .  sensitiveness  of  the  glans  penis  itself  are  heightened  by 
compression  of  that  organ,  in  consequence  of  the  ever  increasing 
fulness  of  the  vessels  of  the  vaginal  mucous  membrane  and  the  two 
vaginal  bulbs. 

"At  the  same  time  the  clitoris  is  pressed  downward  by  the  an- 
terior portion  of  the  compressor  muscle,  so  that  it  is  brought  into 
contact  with  the  dorsal  surface  of  the  glans  and  of  the  body  of  the 
penis;  in  this  way  a  reciprocal  friction  between  these  two  organs 
takes  place,  repeated  at  each  copulatory  movement  made  by  the  two 
parties  to  the  action,  until  at  length  the  voluptuous  sensation  rises 
to  its  highest  intensity  and  culminates  in  the  sexual  orgasm,  marked 
in  the  male  by  the  ejaculation  of  the  seminal  fluid,  and  in  the  female 
by  the  aspiration  of  that  fluid  into  the  gaping  external  orifice  of  the 
cervical  canal ;  so  true,  indeed,  is  this,  that  it  is  a  difficult  matter 
to  give  a  picture  at  once  accurate  and  complete  of  the  phenomena 
attending  the  normal  act  of  copulation.  Whilst  in  one  individual 
the  sense  of  sexual  pleasure  amounts  to  no  more  than  a  barely 
perceptible  titillation,  in  another  that  sense  reaches  the  acme  of 
both  mental  and  physical  exaltation. 

"  Between  these  two  extreries  we  meet  with  innumerable  states  of 
transition.  In  cases  of  intense  exaltation,  various  pathological 
symptoms  make  themselves  manifest,  such  as  quickening  of  the 
general  circulation,  and  violent  pulsation  of  the  arteries ;  the  venous 
blood,  being  retained  in  the  larger  vessels  by  general  muscular  con- 
tractions, leads  to  an  increased  warmth  of  the  body;  and  further, 
this  venous  stagnation,  which  is  still  more  marked  in  the  brain  in 
consequence  of  the  contraction  of  the  cervical  muscles  and  the  back- 
ward flexion  of  the  neck,  may  cause  cerebral  congestion,  during 
which  the  consciousness  and  all  mental  manifestations  are  momentar- 
ily in  abeyance.  The  eyes,  reddened  by  injection  of  the  conjunctiva, 
become  fixed,  and  the  expression  becomes  vacant;  lids  close  con- 


THE  SEXUAL  EPOCH  OF  THE  MENACME.  289 

clusively,  to  exclude  the  light.  In  some,  the  breathing  becomes 
panting  and  labouring;  but  in  others,  it  is  temporarily  suspended,  in 
consequence  of  laryngeal  spasm,  and  the  air,  after  being  pent  up  for 
a  time  in  the  lungs,  is  finally  forcibly  expelled,  and  they  utter  in- 
coherent and  incomprehensible  words.'' 

The  impulses  proceeding  from  the  congested  nerve-centres  are 
confused.  There  is  an  indescribable  disorder  both  of  motion  and 
of  sensation,  the  extremities  are  affected  with  convulsive  twitchings, 
and  may  be  either  moved  in  various  directions  or  extended  straight 
and  stiff;  the  jaws  are  pressed  together  so  that  the  teeth  grind 
against  each  other;  and  certain  individuals  are  affected  by  erotic 
delirium  to  such  as  an  extent  that  they  will  seize  the  unguarded 
shoulder,  for  instance,  of  their  partner  in  the  sexual  act,  and  bite 
it  till  the  blood  flows. 

A  period  of  exhaustion  follows,  which  is  the  more  intense  in  pro- 
portion to  the  intensity  of  the  preceding  excitement.  The  sudden 
fatigue,  the  general  sense  of  weakness,  and  the  inclination  to  sleep, 
which  habitually  affect  the  male  after  the  act  of  intercourse,  are 
in  part  to  be  ascribed  to  the  loss  of  semen ;  for  in  the  female,  how- 
ever energetic  the  part  she  may  have  played  in  the  sexual  act,  a 
mere  transient  fatigue  is  observed,  much  less  in  degree  than  that 
which  affects  the  male,  and  permitting  far  sooner  of  a  repetition  of 
the  act.  "  Triste  est  omne  animal  post  coitum,  praeter  mulierem 
gallumque,"  wrote  Galen,  and  the  axiom  is  essentially  true,  at  any 
rate  so  far  as  the  human  species  is  concerned. 

The  question  has  been  mooted,  and  many  earnest  inquirers  have 
devoted  much  thought  thereto,  whether  in  this  moment  of  most 
intense  sexual  gratification  it  is  the  male  or  the  female  that  ex- 
periences the  greatest  amount  of  pleasure.  As  in  the  case  of  all 
questions  the  data  for  the  solution  of  which  are  at  once  very  various 
and  very  variable,  so  in  this  case  also,  very  different  opinions  have 
been  put  forward.  "  In  fact,"  writes  Roubaud,  "  when  we  take  into 
consideration  all  the  circumstances  by  which  the  intensity  of  sexual 
sensation  is  influenced,  it  may  well  be  doubted  if  it  is  at  all  possible 
to  find  an  a  priori  solution  for  the  problem.  When  we  take  into 
consideration  the  influence  exercised  by  temperament,  constitution, 
and  a  large  number  of  conditions  both  general  and  special,  on 
sexual  sensibility,  we  cannot  fail  to  be  convinced  that  this  problem, 
in  consequence  of  all  the  complicated  characteristics  it  presents,  is 
actually  insoluble. 

In  regard  to  the  pleasure  experienced  in  the  act  of  intercourse, 
a  remarkable  distinction  is  drawn  by  Gutceit.  The  male,  in  every 
case  and  with  every  woman,  experiences  the  full  degree  of  pleasure; 
and  even  though  from  the  mental  point  of  view  this  pleasure  may 
be  enhanced  by  inclination,  attraction,  and  mutual  love,  from  the 


290  THE  SEXUAL  LIFE  OF  WOMAN. 

physical  point  of  view  there  is  no  difference  between  different  acts 
of  intercourse,  so  that  the  cynical  old  Roman  was  right  when  he 
wrote,  "  Sublata  lucerna  nullnm  discrimen  inter  foeminas."  But 
in  the  case  of  the  female  it  is  very  different.  Her  first  experience 
of  sexual  relations  is  a  very  painful  one,  and  this  pain  prevents  all 
enjoyment  as  long  as  it  continues,  as  it  does  in  many  women  for 
one,  two,  or  even  four  weeks.  And  when  this  period  is  once  over, 
not  more  than  two  women  in  every  ten  experience  the  pleasure 
of  sexual  intercourse  in  its  full  intensity.  Of  the  remaining  eight, 
four  have  indeed  an  agreeable  sensation  during  the  rubbing  move- 
ments of  the  sexual  act,  but  it  is  a  long  time  before  they  experience 
a  sensation  analogous  in  its  intensity  to  that  which  in  man  accom- 
panies the  act  of  ejaculation.  In  some  women  it  may  be  six  months 
after  marriage  before  the  true  sexual  orgasm  is  experienced,  in 
others  it  may  be  a  year,  or  even  several  years ;  in  a  considerable 
number  this  does  not  happen  until  after  they  have  given  birth  to 
several  children.  As  a  result  of  numerous  observations  on  this 
point,  Gntceit  asserts  that  in  women  sexual  pleasure  is  experienced 
only  in  intercourse  with  a  man  who  is  beloved,  or  against  whom,  at 
least,  no  repulsion  is  felt ;  and  that  no  pleasure  is  felt  by  a  woman 
in  intercourse  with  a  man  towards  whom  she  feels  an  actual  dis- 
like. Further,  he  maintains,  that  a  woman,  loving  another  man,  and 
feeling  pleasure  in  intercourse  with  him,  has  on  the  other  hand  no 
voluptuous  sensations  during  intercourse  with  her  husband,  whose 
embraces  she  permits  only  from  a  sense  of  duty.  Thus  in  the  male, 
intercourse  is  always  pleasurable,  while  in  the  female,  pleasure  is 
experienced  only  when  certain  conditions  are  fulfilled. 

Contact  with  the  male  genital  organs  stimulates  in  the  female 
the  sensory  nerves  of  the  vulva,  the  vestibule,  and  the  vagina ;  the 
nervous  stimulus  is  transmitted  to  the  cerebral  cortex,  where  it 
gives  rise  to  the  sensation  of  sexual  pleasure,  and  causes,  through 
the  intermediation  of  the  genito-spinal  centre,  a  number  of  reflex 
actions.  As  sensory  nerve  terminals  of  such  reflex  arcs,  the  final 
ramifications  of  the  pudic  branch  of  the  sciatic  plexus  play  the  most 
important  part ;  in  the  clitoris  these  nerves  are  beset  with  a  peculiar 
kind  of  end-bulbs,  the  genital  corpuscles  discovered  by  W.  Kranse; 
from  their  structure  these  corpuscles  seem  admirably  adapted  to 
respond  to  the  very  slightest  stimulation,  producing  voluptuous 
sensations  and  perceptions,  and  giving  rise  to  various  reflex  mani- 
festations. The  first  part  of  the  path  of  the  afferent  impulses  by 
which  sexual  pleasure  is  aroused  is  constituted  by  the  dorsal 
nerves  of  the  clitoris.  The  reflex  changes  consequent  upon  sexual 
excitement  begin  already  in  the  vestibule,  inasmuch  as  the  secretion 
of  Bartholin's  glands,  which  are  compressed  by  the  action  of  the 


THE  SEXUAL  EPOCH  OF  THE  MENACME.  291 

constictor  cunni  muscle,  is  expelled  during  coitus,  the  secretion, 
owing  to  the  situation  of  the  orifices  of  Bartholin's  ducts,  passing 
over  the  external  genitals.  The  clitoris  becomes  erect;  the  blood  in 
the  bulbs  of  the  vestibule,  the  venous  plexus  situated  around  the 
margin  of  the  vestibule  along  the  boundary  between  the  labia  majora 
and  the  labia  minora,  is  pressed  into  the  glans  clitoridis,  the 
erection  and  sensibility  of  this  structure  being  proportionately 
heightened.  By  the  action  of  the  constrictor  cunni  and  ishiocaver- 
nosus  muscles,  the  clitoris,  the  distal  extremity  of  which  is  bent 
downwards  at  a  right  angle,  is  drawn  down  and  pressed  against  the 
penis. 

At  the  entrance  of  the  vagina  is  the  sphincter  vaginae  muscle, 
whose  action  is  reinforced  by  muscular  fibres  running  in  the  middle 
coat  of  the  vagina  itself.  It  is  probable  that  the  muscular  activity 
of  the  vagina  and  the  uterus  facilitates  the  entrance  of  the  semen 
into  the  cavity  of  the  uterus. 

Dorsal  decubitus  is  rightly  regarded  as  the  most  correct  position, 
physiologically  speaking,  for  the  woman  to  assume  during  coitus. 
That  from  the  earliest  times  and  in  the  most  diverse  races,  this 
position  has  been  customary,  is  shown  by  numerous  antique  paint- 
ings and  statues,  and  by  the  reports  of  those  who  have  studied 
the  customs  of  savage  races.  Various  other  positions  are;  how- 
ever, occasionally  assumed;  thus,  Ploss  and  Bartels  report,  that 
among  the  Soudanese,  coitus  is  practiced  in  the  erect  posture,  with 
the  man  standing  behind  the  woman;  that  among  the  Inuits 
(Eskimo),  the  act  is  performed  in  the  manner  usual  among  quad- 
rupeds ;  that  among  the  Swahelis  in  Zanibar,  and  among  the  indi- 
gens  of  Kamschatka,  the  lateral  posture  is  customary;  and  that 
among  the  Australian  blacks,  coitus  is  usually  effected  in  the  crouch- 
ing posture,  both  parties  squatting  on  their  hams.  The  same 
writers  remind  us,  that  in  the  old  calendars  of  the  fifteenth,  six- 
teenth, seventeenth,  and  eighteenth  centuries,  definite  commands 
and  prohibitions  for  the  conduct  of  marital  intercourse  are  to  be 
found,  and  that  lucky  and  unlucky  days,  respectively,  are  specified 
for  the  performance  of  the  act.  These  recommendations  would 
appear  to  be  relics  of  antiquity,  for  in  the  Sanscrit  work  Kok- 
kogam,  under  the  heading  "  Sexual  Intercourse  According  to  the 
Days  of  the  Month,"  exact  instructions  are  given  for  the  proper 
performance  of  coitus. 

In  the  Kamasutra  (the  Indian  ars  amatoria,  a  work  only  in 
recent  days  rendered  accessible  to  European  readers  in  the  trans- 
lation of  R.  Schmidt},  several  chapters  are  devoted  to  the  detailed 
description  of  the  various  methods  of  copulation,  and  rules  are 
given  for  the  carnal  union  'of  man  and  wife.  But,  as  the  Indian 


292  THE  SEXUAL  LIFE  OF  WOMAN. 

author  justly  remarks,  "  Rules  are  of  value  only  for  the  control  of 
moderate  desire ;  when  the  wheel  of  passion  has  once  begun  to  roll, 
to  prescribe  a  course  is  no  longer  of  any  avail."  In  this  work, 
sixty-four  varieties  of  erotic  enjoyment  are  enumerated,  and  we 
find  an  e.rplicatio  coitus  secundum  mensuram,  tempus,  natnram,  de 
tnodis  inter  coitum  procumbendi,  de  minis  coitibus,  de  coitu  inverso, 
dc  viri  inter  coitum  consuetudinibus. 

At  timest  in  order  that  coitus  may  be  effective,  some  other 
position  than  the  natural  one  is  indispensable.  Such  a  necessity 
has  been  recognized  even  by  theologians,  by  whom  any  divergence 
from  nature  in  this  matter  has  usually  been  regarded  as  sinful.  For 
instance,  in  the  work  of  Craisson,  De  Rebus  Venereis  ad  Usum 
Confessariorum,  we  read:  "Situs  naturalis  est  ut  mulier  sit  snccuba 
et  vir  incubus,  hie  enim  modus  aptior  est  effnsionis  seminis  virilis 
et  receptioni  in  vas  femineum  ad  prolem  procreandum.  Unde  si 
coitus  aliter  fiat,  nempe  sedendo,  stando,  de  latere,  vel  praepostere 
(more  pecudum},  vel  si  vir  sit  succubus  et  mulier  incuba,  innaturalis 
est.  .  .  .  Sed  tamen  minime  peccant  conjuges  si  ex  justa  causa 
situm  mutent,  ncmpc  ob  acgritudincm,  vel  viri  pinquetudinem,  vel 
ob  periculum  abortus;  quandoque  ait  St.  Thomas,  sine  peccato  esse 
potest  quando  dispositio  corporis  alium  modiim  non  patitur." 

In  certain  pathological  states,  as  for  the  prevention  of  sterility, 
an  abnormal  posture  during  coitus  may  advantageously  be  recom- 
mended, in  order  to  favour  the  entrance  of  the  semen  into  the 
cervical  canal,  and  to  allow  the  semen  to  stay  longer  in  the  vagina 
before  it  flows  out.  An  old  and  often  efficacious  means  for  this 
purpose  is  the  performance  of  coitus  with  the  woman  in  the  knee- 
elbow  posture.  In  order  to  favour  the  entrance  of  the  semen  into 
the  deeper  portion  of  the  genital  tract,  He  gar  and  Kaltenbach 
recommend  that  after  coitus  the  woman  should  remain  for  some 
time  in  the  knee-elbow  posture,  while  the  man  from  time  to  time 
gently  presses  up  the  anterior  abdominal  wall,  and  then  abruptly 
relaxes  the  pressure. —  In  the  Talmud,  coitus  was  regarded  as  un- 
fruitful if  performed  when  the  woman  was  in  the  erect  posture. 

Casper  reports  the  case  of  a  woman  with  severe  scoliosis,  who  had 
long  remained  sterile,  and  who  only  conceived  (and  was  subse- 
quently happily  delivered)  after  performing  coitus  in  the  abdominal 
decubitus. 

Gueneau  de  Mussy  suggests  the  following,  very  characteristic, 
method  of  ensuring  fertilization,  one  which  also  certainly  dates 
from  great  antiquity:  "Sed  hand  illicit um  mihi  risum  est,  si  post 
diverse  tentamina  diutius  u.vor  infecunda  manserit,  ipsum  maritum 
digitum  post  coitum  in  vaginam  immittere,  et  ita  receptum  semen 
ttteri  osteo  admovere.  Et  cum  ostiolo  uteri  liaeret,  ut  in  pervium 


THE  SEXUAL  EPOCH  OF  THE  MENACME.  293 

canalem  spermatozoidum  motibus  faventibus,  prodeat,  sperare  non 
absurdum."  Eustache  reports  a  case,  the  wife  of  a  physician,  in 
which  this  manoeuvre  was  effective  in  ensuring  conception. 

A  similar  procedure  has  been  employed  with  success  by  Kehrer, 
in  a  case  of  enfeebled  potency  on  the  part  of  the  male,  leading  to 
premature  ejaculation.  A  speculum  was  introduced  into  the 
vagina,  and  through  this  instrument  the  semen,  ejaculated  in  conse- 
quence of  sexual  excitement,  was  introduced  into  the  vaginal  fornix ; 
conception  ensued.  In  an  analogous  manner,  A.  Peyer  recommended, 
in  a  case  of  partial  impotence,  in  which  special  manipulations  were 
needed  to  bring  about  ejaculation,  that  conception  should  be 
favoured  in  the  following  manner:  Erection  having  been  effected 
by  ordinary  sexual  contact,  the  manipulations  needed  to  produce 
ejaculation  were  carried  out,  and  the  penis  was  intromitted  into  the 
vagina  the  moment  before  ejaculation  occurred.  This  has  been 
done  with  fruitful  results.  Englisch  reports  the  case  of  a  hypos- 
padiac  who,  in  order  to  render  coitus  effective,  used  a  condom  in 
the  anterior  extremity  of  which  he  made  an  aperture.  In  this 
way  he  became  the  father  of  three  children. 

In  very  obese  men  with  extremely  protuberant  abdomens,  we 
may  recommend  for  the  furtherance  of  conception  that  they  should 
have  intercourse  with  their  wives  a-parte  posteriori;  and  the  same 
recommendation  may  be  made  in  cases  in  which  the  wife  herself  is 
extremely  obese.  In  Australia,  it  is  said  that  among  the  indigens, 
coitus  is  usually  practiced  a  posteriori;  and  there  is  a  saying  in  the 
Talmud  to  the  effect  that  sexual  intercourse  performed  in  the 
ordinary  manner  does  not  lead  to  the  conception  of  infants  so  good, 
wise,  talented,  and  promising  as  those  whose  conception  is  the 
result  of  coitus  a  posteriori.  Mohammed,  on  the  other  hand,  de- 
clares, "  Your  wives  are  your  tillage,  go  therefore  unto  it  in  what- 
soever manner  ye  will." 

In  cases  of  retroflexion  of  the  uterus,  with  a  markedly  forward 
direction  of  the  vaginal  portion  of  the  cervix,  I  have  recommended 
to  the  husband  that  he  should  perform  coitus  with  his  wife  in  the 
upright  sitting  posture.  In  this  posture  the  fundus  uteri  passes 
downwards  and  forwards,  whilst  the  vaginal  portion  of  the  cervix 
passes  upwards  and  backwards. 

In  cases  of  retroversion  of  the  uterus  with  the  formation  of  a 
cul-de-sac  in  the  posterior  vaginal  fornix,  Pajot  recommends,  with 
the  aim  of  temporarily  restoring  the  uterus  to  a  position  in  which 
the  occurrence  of  conception  is  favored,  that  for  three  or  four  days 
prior  to  coitus  the  patient  should  retain  the  faeces,  eating  the  while 
freely  of  eggs  and  rice,  and  taking  a  small  opium  pill  every  even- 
ing ;  in  cases  of  anteversion,  the  patient  should  retain  her  urine  for 


294  THE  SEXUAL  LIFE  OF  WOMAN. 

a  considerable  time  —  five  or  six  hours  —  before  coitus ;  and  in 
cases  of  lateral  version  he  recommends  that  the  patient  should  have 
intercourse  while  lying  on  that  side  towards  which  the  vaginal  por- 
tion of  the  cervix  is  directed. 

Edis  recommends  that  in  cases  in  which  there  is  sterility  depend- 
ent upon  backward  displacements  of  the  uterus,  that  the  organ 
should  be  replaced  while  the  patient  is  in  the  genu-pectoral  posture, 
and  a  pessary  inserted;  coitus  should  then  be  effected  without  the 
patient's  changing  her  posture. 

In  the  human  species  as  compared  with  the  lower  animals,  there 
has  been  a  notable  diminution  in  the  frequency  of  the  separate  acts 
of  intercourse,  a  diminution  dependent  upon  the  higher  vital  aims 
of  the  former.  Burdock  formulates  as  a  physiological  law  that  the 
frequency  of  sexual  intercourse  is  inversely  related  to  the  duration 
of  the  act. 

Amongst  all  civilized  races,  sexual  intercourse  ceases  during  men- 
struation,'since  in  the  normal  man  there  is  aversion  to  intercourse 
with  a  menstruating  female. 

By  the  Mosaic  law,  intercourse  with  a  woman  during  menstrua- 
tion and  for  seven  days  after  the  cessation  of  the  flow,  was  forbidden 
under  pain  of  death.  The  Talmud  further  ordains  that  a  purifying 
bath  shall  be  taken  by  the  woman  a  week  after  menstruation.  By 
intercourse  itself,  moreover,  both  man  and  woman  were  rendered 
unclean  to  the  evening ;  and,  according  to  the  Mosaic  law,  both  must 
bathe  after  the  act  of  coitus.  In  the  Koran,  also,  intercourse  is  for- 
bidden during  menstruation,  and  until  the  woman  has  been  purified 
with  water.  The  laws  of  Islam  demand  from  a  man  who  marries 
a  virgin  that  he  shall  have  intercourse  with  her  the  first  seven  nights 
in  succession ;  whilst  he  who  marries  a  wife  no  longer  virgin,  needs 
to  visit  her  only  the  first  three  nights  in  succession.  Subsequently, 
during  married  life,  the  Mohammedan  shall  have  intercourse  with 
his  wife  regularly  once  a  week.  Amongst  many  savage  races,  inter- 
course is  forbidden  with  a  woman  during  pregnancy,  the  puerperium, 
and  lactation. 

The  first  act  of  intercourse  is  difficult  and  painful  to  the  virgin. 
At  times  the  rupture  of  the  hymen  is  exceedingly  difficult.  Even 
after  this,  it  is  some  time  before  genuine  pleasure  is  experienced 
in  sexual  intercourse. 

To  the  female,  intercourse  is  harmful  when  performed  with  un- 
due frequency,  or  during  menstruation,  or  indiscriminately  through- 
out pregnancy,  or  during  the  puerperium,  or  incompletely  or  in  an 
unnatural  manner,  or  finally  when  performed  in  an  unsuitable  bodily 
attitude. 

"  Unduly  frequent  performance  of  the  act  of  coitus,"  writes 
Hegar,  "  which  is  liable  to  occur  either  in  marital  or  in  illicit  inter- 


THE  SEXUAL  EPOCH  OF  THE  MENACME.  295 

course,  gives  rise  to  anaemia,  defective  nutrition,  muscular  weak- 
ness, intellectual  and  nervous  exhaustion.  Young  and  healthy  in- 
dividuals recuperate  rapidly  after  excesses  of  brief  duration,  as  is 
often  seen  in  young  married  pairs.  Sickly  and  elderly  persons,  on 
the  other  hand,  are  much  more  severely  affected  by  sexual  excess, 
and  recover  therefrom  but  slowly  if  at  all.  Long  continued  sexual 
excesses  ultimately  wear  out  even  the  strongest." 

Intercourse  effected  by  force,  or  with  a  girl  of  immature  age,  is 
distinguished  as  rape,  a  punishable  offence  both  in  Germany  and  in 
Austria.  The  offence  is  defined  as  extra-marital  intercourse  with  a 
female  under  the  age  of  fourteen  years,  with  or  without  the  latter's 
consent;  or  extra-marital  intercourse  with  a  female  of  any  age 
against  her  will  or  deprived  of  the  power  of  resistance  —  either  by 
the  use  of  actual  force,  by  the  employment  of  threats,  or  by  loss  of 
consciousness.  With  regard  to  the  last  specification,  the  law  re- 
gards as  rape  intercourse  with  a  woman  unable  to  resist  through 
loss  of  consciousness,  whether  that  loss  of  consciousness  is  or  is  not 
produced  by  the  direct  action  of  the  violator. 

In  the  female,  the  act  of  intercourse,  alike  physically,  in  its  natu- 
ral consequences,  and  mentally,  is  at  once  more  difficult  and  of  more 
enduring  results  than  in  the  male.  A  writer  of  the  new  school, 
who  according  to  his  own  admission  has  no  other  interest  than  the 
study  of  the  sexual  life,  writes  of  himself :  "  I  have  often  enough  had 
intercourse  with  members  of  the  other  sex,  in  a  few  cases,  indeed, 
out  of  pure  inclination ;  but  in  all  cases  alike  the  aim  and  the  result 
were  the  same  —  as  soon  as  I  had  gained  my  end,  the  affair  was 
finished.  Passion,  a  bestial  act,  exhaustion,  commonly  a  feeling  of 
loathing;  in  the  best  possible  case  a  fugitive  but  not  an  agreeable 
memory;  voila  tout."  To  women,  such  a  description,  happily,  is 
applicable  only  in  the  most  exceptional  cases. 

With  the  completion  of  coitus,  the  voluntary  and  conscious  action 
of  the  two  parties  to  the  act  is  at  an  end ;  the  subsequent  stages  of 
the  function  of  generation  are  independent  alike  of  consciousness 
and  will. 

When  complete  intromission  of  the  penis  has  been  effected,  and 
ejaculation  takes  place,  the  semen  is  usually  deposited  at  the  os 
uteri  or  in  the  immediate  neighborhood  of  that  orifice.  During 
the  act  of  ejaculation,  a  peristaltic  contraction  of  the  vagina  occurs, 
by  means  of  which  the  semen  at  the  os  uteri  is  subjected  to  a  mod- 
erate degree  of  pressure;  the  contraction  and  the  pressure  may 
perhaps  persist  for  some  little  time  after  the  completion  of  the 
coitus.  In  rabbits  on  heat,  such  contractions  of  the  vagina,  by 
means  of  which  the  semen  was  forced  under  pressure  into  the  in- 
terior of  the  uterus,  have  been  actually  observed. 

During  coitus,  the  uterine  muscle  is  also  active.    During  strong 


296  THE  SEXUAL  LIFE  OF  WOMAN. 

sexual  excitement,  the  uterus  descends  in  the  pelvis,  the  downward 
movement  being  increased  by  the  pressure  on  the  woman's  abdomen. 
The  os  uteri  externuni  is  drawn  open,  and  the  aperture,  hitherto 
flattened,  now  becomes  rounded.  At  the  same  time,  the  secretion  of 
the  cervical  glands  is  expelled,  and  small  quantities  of  semen  are 
sucked  into  the  cervical  canal.  The  plicae  palmatae  offer  a  certain 
hindrance  to  the  entrance  of  the  semen ;  but  the  surface  of  the  in- 
terior of  the  canal  is  rendered  much  smoother  by  the  free  secretion 
of  mucus  by  the  cervical  glands.  Further,  it  appears  highly  probable 
that  during  the  excitement  of  coitus,  the  mouths  of  the  Fallopian 
tubes,  ordinarily  more  or  less  tightly  closed,  become  widely  opened, 
so  that  the  entrance  of  the  spermatozoa  is  favored. 

The  muscular  movements  of  the  uterus  were  observed  by  /.  Beck 
in  a  woman  suffering  from  prolapse.  During  sexual  excitement,  the 
os  uteri  opened  and  closed  rapidly  five  or  six  times  in  succession, 
remaining  at  last  firmly  closed.  Further,  in  bitches  on  heat,  Basch 
and  Hoffmann  observed  the  vaginal  portion  of  the  cervix  to  descend 
in  the  vagina,  the  os  uteri  opened,  mucus  was  extruded",  and  the 
os  was  then  retracted. 

Hohl,  Litzmann,  and  others  have  reported,  that  in  women  en- 
dowed with  great  nervous  susceptibility,  friction  of  the  vaginal 
portion  of  the  cervix  with  the  finger  arouses  sexual  sensation,  with 
rounding  of  the  os  uteri  externum,  descent  of  the  uterus,  and  hard- 
ening of  the  vaginal  portion ;  this  latter  is  regarded  by  Grail v 
Heuntt  and  by  Wernich  as  a  necessary  accompaniment  of  copula- 
tion. Henle  believes  that  the  hardening  and  protrusion  of  the  vagi- 
nal portion  of  the  cervix  are  due  to  a  change  in  the  tension  of  the 
delicate  vessels  of  this  structure,  which  have  an  exceptionally  thick 
muscular  coat ;  Rouget  compares  the  mechanism  with  that  by  which 
erection  of  the  penis  is  produced.  These  authors  consider  that 
sexual  excitement  is  indispensable  for  the  erection  of  the  vaginal 
portion  of  the  cervix. 

Thus,  Hohl  writes :  "  Numerous  observations  have  shown  that  in 
females  endowed  with  a  considerable  degree  of  nervous  suscep- 
tibility, and  especially  in  nulliparae,  during  examination  and  during 
any  increasing  irritation,  not  only  is  there  an  increased  secretion 
of  the  vaginal  mucus,  but  also  a  momentary  descent  of  the  uterus 
and  an  opening  of  the  os  uteri  externum,  so  that  this  orifice  has 
the  appearance  for  the  instant  of  the  open  mouth  of  a  tube.  Litz- 
mann reports  that  during  the  vaginal  examination  of  a  young,  ex- 
tremely erethistic  woman,  the  uterus  suddenly  assumed  a  more 
vertical  position,  and  came  lower  down  in  the  pelvis ;  at  the 
same  time,  the  lips  of  the  cervix  became  equal  in  length,  the  os 
uteri  externum  became  rounded,  soft,  and  penetrable  by  the  finger; 


297 

whilst  the  breathing  and  the  voice  indicated  the  occurrence  of  in- 
tense sexual  excitement.  Rouget  assumes  that  the  body  and  the 
fundus  of  the  uterus  constitute  an  erectile  organ,  which  however 
possesses  capability  for  erection  only  during  the  period  of  ovulation ; 
Hewitt,  on  the  other  hand,  considers  it  extremely  probable  that  the 
erection  may  occur  at  any  time  during  sexual  intercourse,  whether 
ovulation  is  proceeding  or  not.  A.  Wernich  considers,  basing  his 
views  in  part  on  personal  observations,  that  erection  of  the  lower 
segment  of  the  uterus  occurs,  like  erection  of  the  penis,  whenever  a 
moderate  degree  of  sexual  excitement  is  experienced;  in  women, 
however,  he  believes  that  erection  is  seldom  extreme,  and  that  it 
declines  with  the  other  symptoms  of  sexual  excitement,  viz.,  flush- 
ing of  the  face,  moisture  and  glistening  of  the  eyes,  peculiar  groan- 
ing expiration,  etc.  Whereas  during  ovulation,  erection  is  merely 
a  necessary  concomitant  of  the  other  menstrual  processes;  during 
coitus,  erection  not  only  occurs  much  more  powerfully,  but  it  is 
also  an  important  —  perhaps  the  most  important  —  contributory 
factor  in  effecting  fertilization. 

It  is  no  longer  possible  to  accept  the  view  of  earlier  physiologists 
that  the  purpose  of  this  erection  of  the  lower  segment  of  the 
uterus  is  "  to  constitute  with  the  penis  a  continuous  canal  between 
the  male  and  the  female  genital  organs."  Contact  between  the 
glans  penis  and  the  os  uteri  externum  is  not  indeed  an  occurrence 
of  extreme  rarity ;  but,  on  the  other  hand,  it  is  in  no  sense  a  constant 
nor  even  a  frequent  incident  of  sexual  intercourse.  It  is  ejacula- 
tion, especially,  which  is  subserved  by  the  erection  of  the  vaginal 
portion  of  the  cervix.  In  the  female,  ejaculation  occurs  at  the  mo- 
ment of  the  most  intense  sexual  pleasure,  and  is  marked  by  the 
evacuation  from  the  os  uteri  externum  of  a  moderate  quantity  of 
mucous  fluid  with  an  alkaline  reaction.  In  some  cases,  in  which  a 
chronic  discharge  of  this  cervical  mucus  occurs,  it  forms  an 
elongated  coagulum  of  delicate  vitreous  jelly,  the  "mucus-string" 
of  Kristeller.  The  last-mentioned  author  is  of  opinion  that  the 
spermatozoa  slowly,  but  by  active  movements,  find  their  way  along 
this  string  into  the  cavity  of  the  uterus.  This  assumption,  however, 
is  met  by  C.  Mayer  and  Marion  Sims  with  the  objection,  that 
Kristeller 's  observations  were  for  the  most  part  carried  out  on 
women  who  were  out  of  health,  and  that  a  gelatinous  secretion  of 
this  character  obstructs  the  orifice  of  the  cervical  canal,  and  hinders 
the  occurrence  of  conception.  From  the  erection  of  the  portio 
vaginalis  during  sexual  excitement,  and  its  sudden  relaxation  post 
cohabitationem,  Wernich  deduces  the  occurrence  of  a  process  of 
aspiration,  by  which  the  semen  is  drawn  up  through  the  cervical 
canal  into  the  cavity  of  the  uterus;  a  process  which  has  been  seen 


298  THE  SEXUAL  LIFE  OF  WOMAN. 

in  actual  occurrence  in  vivisected  animals.  It  is  said  that  to  many 
women  this  feeling  of  a  process  of  suction  is  so  well  known,  that 
thereon,  in  association  with  the  consequent  almost  complete  ab- 
sence of  mucus  and  seminal  fluid  from  the  vagina,  they  are  accus- 
tomed to  base  a  belief  that  conception  will  occur.  It  is  said  that 
this  aspiratory  activity  on  the  part  of  the  uterus  may  be  perceived 
during  coitus  by  the  male  also  (?).  It  is  assumed  by  Grohe  that 
the  wave  motion  of  the  cilia  of  the  epithelium  lining  the  cervical 
canal,  is  of  importance  in  promoting  the  ascent  of  the  spermatozoa ; 
it  may  be  that  the  vibration  of  the  cilia  exercises  a  motile  stimulus 
on  the  spermatozoa,  it  may  be  that  the  continually  repeated  stroke 
of  the  cilia  serves  to  prevent  the  permanent  agglutination  of  the 
spermatozoa  into  groups. 

According  to  Sims,  the  aspiratory  action  of  the  uterus  is  effected 
in  the  following  manner :  By  the  contraction  of  the  constrictor 
vaginae  superior  muscle,  the  cervix  is  pressed  downwards  against 
the  glans  penis,  and  by  this  pressure  its  contents  are  evacuated ;  the 
parts  then  relax,  the  uterus  suddenly  returns  to  its  normal  state,  and 
thus  the  seminal  fluid  with  which  the  vagina  is  filled  is  drawn  into 
the  interior  of  the  cervical  canal. 

Bichstadt  also  attributes  to  the  uterus  an  aspiratory  force,  depend- 
ent upon  coitus,  and  competent  to  force  into  the  interior  of  the 
uterus  the  semen  ejaculated  into  the  os  uteri.  The  changes  in  the 
uterus  which  are  the  necessary  antecedents  of  this  aspiration, 
namely,  an  engorgement  with  blood  whereby  the  flattened  form  of 
the  uterus  gives  place  to  a  more  rounded  form,  and  the  cavity  of 
the  organ  is  increased  in  capacity,  take  place,  in  the  opinion  of  this 
author,  only  when  during  intercourse  the  woman  has  attained  the 
acme  of  sexual  gratification,  by  which  alone  can  the  aforesaid 
change  in  the  uterus  be  brought  about.  E.  Martin  and  Chrobak 
have  also  directed  attention  to  the  fact,  that  some  importance  in 
this  connexion  must  be  attached  to  the  facultative  enlargement  in 
the  size  of  the  os  uteri  externum. 

Lott,  by  his  researches  into  the  behaviour  of  the  cervix  uteri  in 
relation  to  the  act  of  conception,  is  led  to  the  conclusion  that  the 
locomotive  capacity  of  the  spermatozoa  forms  the  principal  factor 
in  effecting  a  fertilizing  contact  between  the  spermatozoa  and  the 
ovum.  This  locomotive  capacity  may  be  increased  or  diminished 
by  a  number  of  conditions,  among  which  the  principal  are :  the 
activity  of  the  cervix  uteri  (the  ciliated  epithelium)  ;  the  character 
of  the  secretions ;  and  the  position,  shape,  and  size  of  the  cervix. 


THE  SEXUAL  EPOCH  OF  THE  MENACME.  299 

Thus,  this  author  concludes,  the  part  played  in  conception  by  the 
normal  cervical  canal  is  a  purely  passive  one,  with  the  sole  exception 
of  the  activity  of  the  ciliated  epithelium  —  and  the  influence  of  this 
factor  must  be  regarded  as  extremely  doubtful.  That  during 
ejaculation  the  external  orifice  of  the  male  uretha  and  the  os  uteri 
externum  are  in  close  apposition,  is  denied  by  Lott,  who  adduces  in 
support  of  his  views  data  derived  from  comparative  investigations 
on  various  animals.  In  the  dog,  the  configuration  of  the  genital 
organs  is  such  that  it  is  impossible  to  suppose  that  any  apposition 
can  occur;  the  same  is  the  case  with  the  sheep;  and  still  more  so 
with  the  rabbit,  who  possesses  two  quite  distinct  portiones  vagi- 
nales,  projecting  freely  into  the  vagina.  In  the  human  species  also, 
the  character  of  the  walls  of  the  cervical  canal,  where  -in  the  normal 
state  the  plicae  palmatae  may  almost  be  said  to  interlock,  separated 
only  by  a  thin  stratum  of  mucus,  offers  a  hindrance  to  the  entrance 
of  the  ejaculated  semen  by  the  direct  force  of  ejaculation  itself. 
As  regards  the  independent  motile  powers  of  the  spermatozoa,  the 
researches  of  Lott  showed  that  not  only  can  they  overcome  -strong 
capillary  currents,  and  can  traverse  the  width  of  a  coverglass 
(i8mm. —  about  ^4  m-)  in  about  five  minutes;  but  further  that  they 
are  capable  of  migration  through  the  finest  interstices  (those  of  an 
animal  membrane)  provided  that  the  fluid  with  which  the  mem- 
brane is  moistened  is  one  favourable  to  their  vital  activity. 

Kehrer,  who  in  general  supports  the  view  that  the  modus  coeundi 
and  an  active  attitude  on  the  part  of  the  female  have  an  important 
influence  on  the  occurrence  of  conception,  assumes  that  independent 
contractions  of  the  cervix  occur,  whereby  is  expelled  the  delicate 
plug  of  mucus  that  fills  the  cervical  canal  and  offers  an  obstacle 
to  the  passage  of  the  spermatozoa.  He  believes  that  the  duration 
of  the  act  of  intercowrse,  the  mechanical  relations  between  the  penis 
and  the  vagina,  the  activity  of  the  uterine  muscle,  the  secretory 
activity  of  the  utero-vaginal  mucosa  during  the  act,  and  the  posture 
of  the  female  post  coituni,  are  all  important  factors  in  the  occur- 
rence of  conception.  Thus,  he  believes  that  if  during  intercourse 
there  is  a  failure  of  the  uterine  contractions,  which  should  expel 
the  plug  of  cervical  mucus,  the  semen  flows  away  without  effecting 
fertilization ;  if  an  unsuitable  posture  is  assumed  during  intercourse 
the  woman  remains  sterile,  but  can  be  fertilized  without  difficulty 
by  coitus  effected  in  the  proper  manner. 

Haiismann  has  shown,  that  in  the  same  woman,  and  in  similar 
conditions,  spermatozoa  will  on  one  occasion  be  found  in  the  cer- 


300  THE  SEXUAL  LIFE  OF  WOMAN. 

vical  canal,  and  on  another  occasion  will  not  be  found  there;  and 
he  has  further  shown,  that  in  some  women  we  fail  to  find  sperma- 
tozoa in  the  cervical  canal  in  circumstances  in  which,  in  other 
women,  we  regularly  find  them  in  that  situation. 

Far  as  we  may  be  from  a  complete  knowledge  of  the  conditions 
upon  which  conception  depends,  this  at  least  is  certain,  that  the 
passage  of  spermatozoa  through  the  os  uteri  externum  is  a  sine 
qua  non  of  fertilization.  Indeed,  it  would  seem  that  we  must  ac- 
cept as  true  the  assumption  of  Meyerhofer,  that  fertilization  is 
possible  only  if  the  semen  passes  at  once  into  the  cervical  canal, 
mingles,  that  is,  at  once  with  the  alkaline  cervical  mucus  —  unless, 
indeed,  the  coitus  takes  place  during  the  catamenial  flow,  when 
the  blood  has  neutralized  the  acid  reaction  in  the  vagina,  or  takes 
place  when  some  morbid  condition  has  had  the  same  result.  The 
theory  of  Johann  Miiller,  regarding  the  piston-like  action  of  the 
penis  during  coitus,  by  which  the  semen  is  actually  forced  through 
the  cervix,  must  be  rejected;  equally  unsound  is  Hoist's  assumption 
that  during  intercourse  the  semen  is  ejaculated  through  the  enlarged 
cervical  canal  directly  into  the  cavity  of  the  uterus.  It  would  ap- 
pear, however,  to  be  a  necessary  condition  of  fertilization,  that  the 
semen  should  be  ejaculated  into  the  uppermost  segment  of  the 
vagina,  so  that  the  fluid  comes  into  actual  contact  w'th  the  os  uteri 
externum ;  it  may  be  that  the  alleged  aspiratory  force  of  the  uterus 
then  comes  into  play,  by  means  of  which  the  semen  is  sucked  into 
the  cavity  of  that  organ ;  it  may  be,  on  the  other  hand,  that  Beigel 
is  right  in  his  theory  of  the  existence  of  a  rcccptacitlnui  scminis, 
formed  by  the  anterior  and  posterior  lips  of  the  cervix  uteri  and 
the  uppermost  segment  of  the  vagina  —  in  this  space,  he  supposes, 
a  part  of  the  semen  is  retained  in  contact  with  the  orifice  of  the 
cervical  canal. 

It  is,  also,  exceedingly  probable  that  during  coitus  a  reflex  ner- 
vous mechanism  becomes  active,  by  means  of  which  the  uterine 
orifices  of  the  Fallopian  tubes  are  opened,  the  vaginal  portion  of 
the  cervix  descends  in  the  vagina,  the  os  uteri  externum  enlarges, 
the  orifice  becoming  rounded  where  before  it  was  flattened,  and 
finally  small  quantities  of  semen  may  be  aspirated  into  the  cavity  of 
the  uterus. 

I  further  regard  it  as  important  in  promoting  conception,  that 
simultaneously  with  the  changes  above  described,  the  reflex  ner- 
vous stimulation  should  lead  to  the  secretion  by  the  cervical  glands 
of  a  gelatinous  material,  alkaline  in  reaction,  and  therefore  adapted 


THE -SEXUAL  EPOCH  OF  THE  MENACME.  301 

to  increase  the  locomotive  powers  of  the  spermatozoa,  so  that  these 
latter,  aided  by  the  activity  of  the  ciliated  epithelium  lining  the 
cervical  canal,  will  gain  the  interior  of  the  cavity  of  the  uterus,  and 
thence  pass  onwards  to  the  Fallopian  tubes.  The  significance  of  the 
glands  in  the  mucous  membrane  lining  the  cervical  canal  has  hitherto 
been  underestimated  in  this  connexion. 

Whereas  in  the  primitive  state  of  mankind,  among  savage  races 
at  the  present  day,  as  among  our  own  prehistoric  ancestry,  naked- 
ness is  the  rule,  so  also  intercourse  in  these  circumstances  is  ef- 
fected altogether  without  any  regulation  by  law  or  custom,  on  the 
mere  prompting  of  unbridled  natural  passion,  and,  moreover,  there 
is  the  fullest  promiscuity  in  sexual  relations ;  but  civilization  has  led 
man  to  impose  restraints  upon  sexual  intercourse,  and  has  intro- 
duced marriage  as  a  sacred  institution.  Among  certain  primitive 
peoples,  however,  among  whom  the  wives  are  common  to  all  the 
men,  transitory  pairings  nevertheless  occur,  especially  when  a 
woman  becomes  pregnant ;  to  cease,  however,  during  .the  period  of 
lactation.  "  This  is  the  origin  of  marriage,  which  has  evolved 
from  rape  and  prostitution,  as  law  has  evolved  from  crime  *' 
(Lombroso).  This- author  makes  an  interesting  observation  when 
describing  the  entire  freedom  of  sexual  intercourse'  that  obtains 
among  the  Red  Indians  of  North  America,  to  the  effect  that  "  often, 
times  of  general  promiscuity  occur,  as  with  rutting  animals,  gen- 
erally in  the  warm  season  of  the  year,  when  nutriment  is  abundant ; 
it  is  difficult  to  indicate  any  distinction  between  the  tumultuous 
orgies  of  the  baboon,  and  those  of  the  Australian  Blackfellows, 
among  whom  the  sexes  keep  apart  during  the  greater  part  of  the 
year,  to  intermingle  like  rutting  beasts  during  the  season  of  the 
yam-harvest." 

The  paths  of  civilization,  from  the  complete  promiscuity  of  sexual 
intercourse  to  the  lofty  ideal  of  life-long  monogamic  union,  has  not 
been  a  straightforward  one,  but  has  been  marked  by  various  aberra- 
tions of  sexual  relationship ;  hetairism,  prostitution,  polyandry,  in- 
cest, rape,  the  jus  primae  noctis,  etc.  The  anthropologist  is  able 
to  trace  the  successive  stages  of  the  development  of  the  institution 
of  monogamic  marriage ;  the  community  of  wives  within  the  clan ; 
free  sale  of  wives  and  daughters ;  bestowal  of  a  man's  wife  or  con- 
cubine for  the  honour  of  a  guest ;  ritual  prostitution  for  the  honour 
of  the  gods  and  at  numerous  religious  festivals ;  aesthetic  and  lite- 
rary hetairism,  with  bestowal  of  favours  according  to  free  inclina- 
tion ;  community  of  wives  among  all  males  of  the  same  family ;  the 


LlliKAKV  IT 
COLLlZ(£lE   Ulr   USTEUFA 


302  THE  SEXUAL  LIFE  OF  WOMAN. 

claim  of  the  wife  to  as  many  as  five  or  six  husbands;  the  right  of 
brothers  to  their  sisters;  the  defloration  of  virgins  by  the  priests  in 
heathen  temples;  the  temporary  possession  of  the  wife  by  the  chief 
of  the  community,  prior  to  her  possession  by  her  permanent  hus- 
band ;  defloration  of  the  bride  by  the  bonze  before  her  marriage ; 
the  feudal  right  of  the  mediaeval  seigneur  to  the  prhna  nox  of  the 
bride  of  his  retainer. 

In  the  lower  stages  of  civilization,  copulation  appears  so  natural 
an  action  that  it  is  performed  in  public  entirely  without  shame. 
Thus,  Cook,  in  his  first  voyage,  describes  having  seen  an  indigen 
engage  in  sexual  intercourse  with  a  girl  of  eleven  years,  under  the 
very  eyes  of  the  queen,  with  whom  Cook  was  then  having  audience ; 
the  sexual  act  was,  according  to  Cook,  the  favourite  topic  of  con- 
versation between  the  sexes.  Herodotus  reports  that  many  peoples 
of  antiquity  had  no  regard  for  privacy  in  sexual  intercourse,  but 
that,  like  the  lower  animals,  they  had  connexion  in  any  company. 
In  the  Bible,  also,  it  is  recorded  that  sexual  intercourse  was  prac- 
tised in  public :  "  So  they  spread  Absalom  a  tent  upon  the  top  of 
the  house ;  and  Absalom  went  in  unto  his  father's  concubines  in  the 
sight  of  all.  Israel."  (II.  Samuel,  XVI.  22.)  According  to 
Athcnaeus,  the  Etruscans,  at  their  public  banquets,  were  equally  un- 
restrained. Plutarch  reports  that  among  the  Spartans  the  maidens 
and  the  young  men  went  about  naked  together.  Even,  indeed,  after 
the  sense  of  modesty  had  begun  to  develop,  it  was  long  before  any 
secret  was  made  about  the  act  of  intercourse.  In  classical  antiquity, 
it  was  very  frequently  the  subject  of  pictorial  and  plastic  representa- 
tion. Even  in  more  recent  days,  there  have  been  artists  who  have  not 
hesitated  to  depict  the  sexual  act:  thus  we  have  the  Venus  with  a 
Faun  by  Caracci;  the  Jupiter  and  lo  of  Correggio;  the  Leda  and  the 
Swan  of  Tintoretto;  and  similar  pictures  by  Luca  Giordano,  Rubens, 
Titian,  and  Franceschini. 

Even  in  the  early  centuries  of  the  Christian  era,  the  sect  of  the 
Adamites  practised  intercourse  openly  in  the  light  of  day,  on  the 
ground  that  that  which  was  right  in  the  dark,  could  not  be  wrong 
in  the  light.  The  same  is  reported  of  the  sect  of  Turlnpins,  in 
France  in  the  fourteenth  century.  We  cannot  refrain  from  quoting 
at  length  from  Lombroso  and  Ferrero  a  passage  relating  to  the 
evolution  of  sexual  manners  in  the  female  sex  (Woman  as  Criminal 
and  Prostitute)  :  "  In  the  lowest  stages  of  development,  the  feel- 
ing of  modesty  is  entirely  wanting;  limitless  freedom  in  sexual 
intercourse  is  the  general  rule;  and  even  where  no  system  of 


•~:  f~,  rr  I  t  ^        r      /-.  r  /  /    t  '-    i  r-.  '  /  t  i 


THE  SEXUAL  EPOCH  OF  THE  MENACME.  303 

promiscuity  prevails,  marriage  rather  fosters  than  discourages  pros- 
titution, especially  in  countries  in  which  husbands  are  accustomed 
to  expose  their  wives  for  sale.  This  fact  may  be  brought  into  rela- 
tion with  the  well  known  lasciviousness  of  apes  and  other  animals 
high  in  the  scale,  showing  that  sexual  excitability  increases  parl 
passu  with  intelligence,  so  that  to  man  it  is  as  impossible  as  to  an 
ape  to  satisfy  his  sexual  needs  with  a  single  female.  Whilst  among 
the  apes,  a  single  male  possesses  a  number  of  wives,  we  find  in  the 
gregarious  life  of  primitive  man  that  community  of  wives  has  taken 
the  place  of  polygamy,  which  institution,  however,  reappears  in  a 
higher  stage  of  culture  for  the  benefit  of  the  more  powerful  mascu- 
line natures. 

"  To  the  dominion  of  prostitution  as  a  normal  institution  succeeds 
the  period  in  which  it  persists  as  a  variously  metamorphosed  sur- 
vival:  it  may  be  as  the  duty  of  the  wife  to  surrender  her  person  to 
any  other  male  of  the  same  family ;  or  the  woman  may  have  to 
bestow  her  favors  on  a  religious  or  political  chief,  as  in  the  institu- 
tion of  temple-prostitution,  where  the  wife  must  give  herself,  it  may 
be  to  any  one  and  at  any  time,  or  it  may  be  to  defined  persons  only 
and  at  stated  festivals.  Frequently  we  meet  with  another  develop- 
ment of  prostitution,  finding  that  while  the  wife  must  remain  chaste, 
the  unmarried  woman  is  allowed  unrestricted  intercourse ;  or,  again, 
the  wife  at  certain  definite  periods  may  dispense  with  fidelity  to  her 
husband,  and  return  to  the  primitive  condition  of  promiscuity.  In 
certain  instances  prostitution  is  combined  with  the  duties  of  hos- 
pitality, and  marriage,  though  approximating  to  the  monogamic 
ideal,  must  tolerate  the  intrusion  of  the  guest  into  the  marriage 
bed." 

"  In  a  third  period,  prostitution  no  longer  fills  the  place  of  a 
traditional  survival,  but  is  a  morbid  manifestation  confined  to  a  cer- 
tain class  of  the  community.  But  bridging  this  transition  of  pros- 
titution from  a  normal  to  a  morbid  manifestation,  we  have  the 
remarkable  phenomenon  of  aesthetic  prostitution.  Thus,  in  India 
and  in  Japan,  an  agreeable  class  of  prostitutes  practices  the  arts  of 
singing  and  dancing,  and  forms  a  privileged  caste ;  similarly,  in  the 
most  flourishing  period  of  Grecian  culture,  the  leading  men  of  the 
time  formed  a  social  circle  around  the  hetairae,  from  whom  they 
derived  a  fruitful  stimulus  to  intellectual  and  political  activity.  In 
this  respect,  history  repeated  itself  in  Italy  in  the  sixteenth  century. 
Alike  in  classical  Greece  and  in  mediaeval  Italy,  this  aesthetic  pros- 
titution fanned  the  flames  of  a  period  of  intense  spiritual  activity  — 


304  THE  SEXUAL  LIFE  OF  WOMAN. 

for  in  individuals  as  in  races,  intellectual  quickening  is  ever  accom- 
panied by  erotic  excitability." 

The  unbridled  passion  of  the  primitive  races  of  mankind,  the 
coercive  love  of  beauty  felt  by  the  ancient  Greeks,  the  swelling  flood 
of  erotism  of  the  great  mass  of  people  of  all  times,  is  gradually 
guided  into  the  quiet  channel  of  the  marriage  bed ;  and  even  though 
monogamjc  marriage  is  incapable  of  fully  providing  for  all  mani- 
festations of  sexual  passion,  still,  from  the  medical  point  of  view, 
we  must  maintain  that  marriage  is  for  women  the  most  hygienic 
and  the  most  proper  means  of  gratification  of  the  sexual  impulse. 

Conception. 

The  union  between  ovum  and  spermatozoon,  whereby  fertilization 
is  effected,  appears  to  occur  in  the  human  species  as  a  rule  in  the 
outer  third  of  the  Fallopian  tube,  the  ampulla  of  this  structure 
(receptacuhnn  seminis  in  Henle's  terminology)  serving  to  store  the 
semen  for  a  considerable  period ;  in  the  lower  animals,  the  usual 
occurrence  of  fertilization  in  this  region  has  been  established  by 
direct  observation.  The  open  mouth  of  the  tube  -receives  the  ma- 
ture ovum,  guided  thither  from  the  ovary  by  appropriate  movements 
of  the  ovarian  fimbriae;  these  movements  have  been  seen  in  active 
occurrence  in  the  guinea  pig  by  Hensen.  Once  within  the  tvibe,  the 
onward  movement  of  the  ovum  is  effected  by  the  cilia  of  the  epithe- 
lium lining  of  the  canal. 

His  has  formulated  the  theory  that  in  the  human  species  fertiliza- 
tion is  possible  only  in  the  uppermost  segment  of  the  tube;  an  as- 
sumption that  is  probable  enough,  but  cannot  be  regarded  as 
definitely  established.  An  analogy  certainly  exists  among  the  lower 
divisions  of  the  animal  kingdom,  for  Coste,  His,  and  Ohlschliiger 
have  proved  that  an  ovum  which  passes  through  the  Fallopian  tube 
without  being  fertilized,  undergoes  notable  alterations.  Further, 
Costc  has  shown,  in  the  case  of  the  ovum  of  the  domestic  fowl,  that 
this  is  no  longer  capable  of  being  fertilized  after  it  has  passed 
through  the  upper  segment  of  the  oviduct.  Other  authorities,  how- 
ever, namely  Lcnventhal,  Mayrhofer,  and  Wyder,  oppose  the  exten- 
sion of  this  rule  to  the  human  species.  Lauren  thai  assumes  that  in 
the  human  female,  fertilization  ordinarily  occurs  in  the  cavity  of 
the  uterus,  in  the  wall  of  which  the  unfertilized  ovum  has  already 
embedded  itself;  and  he  supports  his  contention  by  the  statement 
that  spermatozoa  are  not  to  be  found  in  the  Fallopian  tubes  or  on 
the  surface  of  the  ovaries.  Mayrhofer  and  Wyder  point  out  that 


THE  SEXUAL  EPOCH  OF  THE  MENACME.  305 

the  movement  of  the  cilia  of  the  ciliated  epithelium  is  in  the  interior 
of  the  uterus  in  an  upward  direction,  but  in  the  Fallopian  tubes  is 
downwards  in  the  direction  of  the  uterus. 

The  contention  of  Lowenthal  was  disproved  by  Birch  and  Hirsch- 
feld,  who,  in  a  prostitute  dying  during  the  act  of  intercourse,  found, 
fifteen  hours  after  death,  living  spermatozoa  in  the  Fallopian  tubes. 
On  the  other  hand,  more  recent  investigations,  those,  for  instance, 
of  Hofmeier,  Mandl,  and  Bonn,  have  confirmed  the  data  given 
above  with  regard  to  the  direction  of  the  ciliary  movement  in  the 
interior  of  the  genital  passages.  Moreover,  O.  Becker  has  shown 
that  the  ciliated  epithelium  of  the  tubes  extends  over  the  fimbriae 
and  even  on  to  the  adjoining  pavement  epithelium  of  the  peri- 
toneum ;  and  he  believes  that  the  ciliary  movement  of  this  region 
keeps  up  a  constant  current,  the  purpose  of  which  is  to  sweep  the 
ovum  into  the  ostium  of  the  tube,  and  thence  down  towards  the 
uterus.  Lode  has  adduced  positive  experimental  evidence  of  the 
occurrence  of  such  a  movement  of  translation. 

The  general  result  of  anatomical  investigation  is,  that  the  con- 
jugation of  the  ovum  with  the  spermatozoon  takes  places  in  the  am- 
pulla of  the  Fallopian  tube ;  but  it  is  established  that  fertilization 
may  also  take  place  lower  down  in  the  tubes,  or  in  the  uterine  cavity, 
or  even  on  the  surface  of  the  ovary,  i.  e.,  in  the  abdominal  cavity. 

The  fertilization  of  the  mature  ovum  —  maturation  having  oc- 
curred within  the  ovarian  follicle  before  its  rupture  —  has  been 
shown  by  numerous  researches  on  the  ova  of  other  animals  to  con- 
sist in  the  fusion  of  the  male  and  the  female  nucjear  substance ;  and 
it  appears  that  of  the  enormous  number  of  spermatozoa,  estimated 
by  Lode  at  226  million  at  a  single  ejaculation,  that  enter  the  female 
genital  passage,  but  a  single  one  penetrates  the  ovum.  Towards 
the  head  of  this  spermatozoon  there  extends  from  the  surface  of 
the  ovum  a  process,  flat  at  first,  but  becoming  more  and  more 
prominent,  until  it  surrounds  the  head,  and  fuses  with  it.  The 
motile  tail  of  the  spermatozoon  disappears,  whilst  the  head,  which 
has  now  passed  through  the  vitelline  membrane  and  entered  the 
•ovum,  assumes  the  appearance  of  a  nucleus,  and  is  called  the  male 
pro-nucleus.  The  original  nucleus  of  the  ovum  has  previously  pre- 
pared itself  for  fertilization  by  the  extrusion  through  the  vitelline 
membrane  of  portions  of  its  substance  (known  as  polar  globules), 
and  now  constitutes  the  female  pro-nucleus.  Towards  this  latter, 
situated  somewhere  near  the  centre  of  the  cell,  the  male  pro-nucleus 
continues  to  move,  the  vitelline  granules  meanwhile  being  disposed 
20 


306 


THE  SEXUAL  LIFE  OF  WOMAN. 


round  about  it  in  radiating  lines,  forming  a  star-shaped  figure. 
Having  come  into  contact,  the  two  pro-nuclei  fuse  completely  to 
form  a  new  nucleus,  the  nucleus  of  the  now  fertilized  egg-cell. 
The  result  of  fertilization  is  the  formation  of  the  first  segmentation- 


FIG.  ssA.—  First  Stage.  FIG.  556.— Second  Stage, 

Entrance    of   a    spermatozoon   into    the    ovum    of   ascaris    mezalocephala. 

After  preparations  by  M.  Nusbaum.      (Half  of  the  ova  only  are  depicted.) 

sphere,  from  which,  by  further  subdivision,  the  new  individual  is 
formed.  Thus  is  effected  that  which  Hippocrates  describes  in  the 
words:  "  The  seed  possessed  both  by  man  and  by  woman,  flow  to- 
gether from  all  parts  of  the  body ;  the  fruit  is  formed  by  the  min- 
gling of  the  two  seeds." 

The  most  favourable  period  for  the  occurrence  of  fertilization 
appears  to  be  when  intercourse  takes  places  from  eight  to  ten  days 


FIG.  56. —  Ovum   of  Asterakanthion        FIG.  57. —  Fusion    of   male   pro-nu- 
ten  minutes  after  fertilization.  cleus  and  female  pro-nucleus  to  form 

the   segmentation  nucleus  of    the  fer- 
tilized ovum. 


after  the  termination  of  the  menstrual  flow.  In  248  instances  in 
which  the  date  of  the  fruitful  coitus  was  exactly  known,  it  was 
ascertained  by  Hasler  that  in  82^2  per  cent,  of  all  cases,  conception 
was  effected  in  the  fourteen  days  succeeding  the  menstrual  period. 
In  general  it  may  be  stated  that  the  theory  of  the  periodicity  of 
ovulation  and  of  the  causal  relation  of  this  process  to  menstruation, 
has  not  been  shaken  bv  the  result  of  researches  recentlv  undertaken 


THE  SEXUAL  EPOCH  OF  THE  MENACME. 


307 


by  opponents  of  that  theory;  hence  it  appears  that  the  fertilized 
ovum  is  the  ovum  of  the  last  completed  menstruation. 

Already  in  the  writings  of  the  old  Indian  physician  Susruta,  we 
find  expression  of  the  view  that  the  period  that  immediately  suc- 
ceeds the  cessation  of  the  menstrual  flow  is  one  most  favourable  to 
conception.  "  The  time  of  generation,"  he  says,  "  is  the  twelfth 
night  after  the  commencement  of  menstruation."  In  the  Jewish 
Talmud,  the  day  before  the  onset  of  menstruation,  and  the  days  im- 
mediately succeeding  the  cessation  of  the  flow,  are  indicated  as 
those  most  favourable  to  the  occurrence  of  conception;  moreover, 
in  the  Talmud,  notwithstanding  the  fact  that  intercourse  during 
menstruation  is  prohibited  on  pain  of  death,  and  that  coitus  is  not 


FIG.  58. —  Passage  of  spermatozoon  FIG,  59. — Ovum  of  scorpaena  scrofa 
through  the  zona  pellucida  of  the  thirty-five  minutes  after  fertiliza- 
ovum  of  asterakanthion.  tion. 

regarded  as  permissible  until  the  lapse  of  twelve  clear  days  after 
the  cessation  of  the  flow,  nevertheless  the  assertion  is  made  that 
intercourse  during  menstruation  may  lead  to  conception. 


FIG.  60. —  Male    pro-nucleus    and    female     pro-nucleus  in  fertilized    ovum 
of  frog,  prior  to  the  formation  of  the  segmentation  nucleus. 

Hippocrates  writes:  Hac  nempe  post  menstruam  purgationem 
utcro  concipat.  Aristotle  says :  Plerasque  post  mensum  ftuxum 
iwnnullas  z>cro  fluentibus  adhuc  men-struts.  Galen  writes:  Hoc 
antem  conccptionis  tcmpus  est  vel  incipicntibus  vcl  cessantibus 
menstruis. 


308  THE  SEXUAL  LIFE  OF  WOMAN. 

Soranus  writes  to  a  similar  effect :  Just  as  the  soil  is  suitable  only 
at  certain  seasons  for  the  reception  of  the  seed,  so  also  in  the 
human  race  intercourse  does  not  always  take  place  at  a  time  suited 
for  the  reception  of  the  semen.  To  be  effective,  coitus  must  occur 
at  the  proper  time.  .  .  .  The  act  of  intercourse  that  is  to  lead 
to  conception  may  best  occur  either  just  before  or  just  after  the 
menstrual  flow,  when,  moreover,  there  is  strong  desire  for  the 
sexual  embrace,  and  neither  when  the  body  is  fasting,  nor  when  it 
is  full  of  drink  and  undigested  food.  •  The  time  before  menstrua- 
tion is,  however,  unsuitable,  for  then  the  womb  is  heavy  from  the 
flow  of  blood,  and  two  conflicting  tendencies  will  come  into  opera- 
tion, one  for  the  absorption  of  material  and  the  other  for  its  out- 
flow. During  menstruation,  again,  conception  is  unlikely  to  occur, 
for  then  the  semen  is  wetted  and  washed  away  by  the  flowing  blood. 
The  sole  proper  time  is  that  immediately  after  the  flow,  when  the 
womb  has  freed  itself  from  its  humours,  and  warmth  and  moisture 
stand  in  harmonious  relationship. 

Among  many  of  the  castes  of  Hindustan,  it  is  a  religious  ordinance 
that  on  the  fourth  day  of  menstruation  a  man  shall  have  intercourse 
with  his  wife,  "  since  this  day  is  that  on  which  conception  is  most 
likely  to  occur."  Indian  physicians  advise,  in  order  to  bring  about 
conception,  "  that  coitus  be  effected  always  as  soon  as  the  menstrual 
flow  has  ceased,  at  the  end  of  the  day,  and  when  the  lotus  has 
closed."  In  Japan,  medical  opinion  is  to  the  effect  that  a  woman 
is  capable  of  conceiving  during  the  first  ten  days  after  menstrua- 
tion, but  not  later  (Ploss  and  Bartels}. 

The  view  that  the  first  days  of  the  inter-menstrual  interval  are 
those  most  favourable  to  the  occurrence  of  conception,  is  further 
confirmed  by  the  statistical  data  collected  by  Lowcnfcld,  A  hi f  eld, 
Hccker,  and  Veit;  and  it  appears  that  as  the  date  of  the  next  men- 
struation is  approached,  there  is  a  continual  decline  in  the  frequency 
of  conception;  just  before  the  flow,  conception  hardly  ever  occurs. 
Hcnsen,  from  the  records  of  248  conceptions  in  which  the  date  of 
the  fruitful  intercourse  was  exactly  known,  draws  the  following  con- 
clusions : 

1.  The  greatest  number    of    conceptions    follow  coitus  effected 
during  the  first  days  after  the  cessation  of  the  menstrual  flow. 

2.  When  coitus  is  effected  during  menstruation,  the  probability 
of  conception  increases  day  by  day  as  the  end  of  the  flow  is  ap- 
proached. 

3.  The  number  of  conceptions  following  coitus  effected  shortly 
before  menstruation  is  minimal. 


THE  SEXUAL  EPOCH  OF  THE  MENACME.  309 

4.  However,  there  is  no  single  day  either  of  the  menstrual  flow 
or  of  the  inter^menstrual  interval,  on  which  the  possibility  of  the 
occurrence  of  conception  can  be  excluded. 

Fcokstitow  has  drawn  up  from  statistical  data  an  ideal  "  concep- 
tion-curve," which  teaches  that  conception  most  readily  ensues  upon 
coitus  effected  soon  after  the  end  of  the  menstrual  flow,  in  the  first 
week,  that  is  to  say,  of  the  inter-menstrual  interval ;  moreover,  the 
curve  shows  that  the  highest  percentage  of  conceptions  occurs  on 
the  very  first  day  after  the  cessation  of  the  flow,  and  that  after 
this  day  the  percentage  of  conceptions  declines.  The  percentage 
frequency  of  conceptions  from  coitus  effected  on  the  last  day  of 
menstruation,  and  on  the  first,  ninth,  eleventh,  and  twenty-third 
days,  respectively,  of  the  inter-menstrual  interval,  is  expressed  by 
the  ratio  48:62:13:9:1;  and  between  the  points  given,  the  course 
of  the  curve  is  almost  rectilinear.  The  probability  of  the  occur- 
rence of  conception  on  the  twenty-third  day  of  the  interval  (on 
which  day.  the  curve  reaches  its  lowest  point),  is  one-sixty-second 
of  the  maximum  probability. 

The  proper  performance  of  coitus  depends  upon  the  potentia 
coeundi  of  the  male ;  the  attainment  of  conception  depends  upon  his 
potentia  generandi.  The  potentia  generandi  demands  from  the  man 
the  functional  competence  of  the  testicles,  the  perviousness  of  the 
seminal  passages  (namely,  of  the  vasa  deferentia  and  the  urethra), 
the  secretion  of  a  normal  semen,  and,  finally,  a  proper  formation  of 
the  penis,  whereby  during  ejaculation  the  semen  may  be  deposited 
in  sufficient  proximity  to  the  os  uteri  externum. 

Normal  semen  is  a  whitish,  semi-transparent  fluid,  of  the  con- 
sistency of  thin  cream.  It  contains  aggregations  of  a  nearly 
spherical  shape,  consisting  of  a  vitreous,  transparent,  colourless  or 
light  yellow,  gelatinous,  elastic  substance.  Under  the  microscope 
this  substance  has  a  hyaline  appearance,  and  exhibits  in  its  interior 
innumerable  clear  spaces  of  varying  size,  which  are  apparently  filled 
with  a  clear  fluid.  Not  infrequently,  these  spaces  are  extremely  nar- 
row and  therewith  greatly  elongated  and  disposed  in  parallels,  so 
that  the  whole  substance  thus  obtains  a  striated  appearance.  When 
treated  with  water,  this  material  becomes  whitish  and  non-trans- 
parent, and  assumes  under  the  microscope  a  finely  granular  aspect. 
When  allowed  to  stand  without  agitation  for  twenty-four  hours, 
this  substance  dissolves  and  becomes  so  intimately  mingled  with  the 
seminal  fluid  that  it  can  no  longer  be  clearly  differentiated  there- 
from. In  all  probability  it  is  merely  a  secretory  product  of  the 
seminal  vesicles. 


3io  THE  SEXUAL  LIFE  OF  WOMAN. 

The  truly  fluid  portion  of  the  semen  contains  the  following 
morphological  elements : 

1.  Microscopic    aggregations    of    hyaline    substance,    variously 
shaped. 

2.  Very  numerous  granules,  small  and  extremely  pale,  albuminous 
in  their  nature,  and  disappearing  on  treatment  with  acetic  acid. 

3.  A  small  number  of  rounded  or  oval  cells,  about  the  size  of 
leucocytes,  containing  one,  or  sometimes  two  small  round  nuclei. 

4.  Prostatic  calculi.     These  are  an   inconstant  constituent,  but 
are  very  frequently  met  with  after  repeated  coitus.     According  to 
some  observers  they  are  derived  also  from  the  bladder  and  urethra. 
They  are  distinguished  by   their  yellowish  colour,  their  irregular 
form   (sometimes  triangular,  sometimes  rounded  or  oval),  and  by 
their  characteristic  structure.     They  are  composed  of  a  substance 
arranged  in  concentric  laminae,  which  in  the  centre  has  a  granulated 
appearance;  they  often  exhibit  one  or  more  oval  nuclei. 

5.  Spermatozoa  in  countless  numbers. 

In  exceptional  cases  we  find  as  additional  morphological  elements, 
especially  in  elderly  people,  scattered  erythrocytes,  cylinder-epithe- 
lium cells,  and  masses  or  granules  of  yellow  pigment. 

The  spermatozoa  are  about  fifty  micromillimetres  in  length.  Two 
parts  may  be  distinguished  in  each,  a  head  and  a  tail.  The  head, 
four  or  five  micromillimetres  in  length,  is  flattened,  and  differs  in 
apparent  shape  —  though  generally  more  or  less  pear-shaped  — 
according  as  to  whether  it  is  seen  sideways  or  on  the  flat. 

The  tail,  which  is  about  forty-five  micromillimetres  in  length,  nar- 
rows from  before  backwards.  The  fine  posterior  extremity  is  said 
to  contain  the  contractile  element,  so  that  it  is  upon  this  portion 
that  the  familiar  movements  of  the  spermatozoa  depend  (Fig.  61). 

The  speramatozoa  are  made  up  of  a  substance  very  rich  in 
sodium  chloride,  and  strongly  resistent  to  reagents  and  to  putrefac- 
tion. In  consequence  of  their  richness  in  mineral  constitutents,  the 
ash,  when  they  are  calcined,  retains  their  original  form. 

The  movements  of  the  spermatozoa  can  be  properly  observed  only 
in  fresh,  pure  semen  (Fig.  62). 

If  freshly  ejaculated  semen  is  treated  with  water,  the  movements 
of  the  spermatozoa  very  shortly  cease,  and  their  tails  become  rolled 
up  in  a  spiral  form.  - 

If  semen  is  left  undisturbed  for  twenty-four  hours  or  longer,  the 
vitreous  substance  dissolves  in  the  surrounding  fluid,  and  this  latter 
separates  into  two  layers,  an  upper  which  is  thinner,  and  a  lower, 


3" 


which  is  thicker  and  non-transparent.  In  the  former,  the  morpho- 
logical elements  are  found  but  sparingly,  whilst  in  the  latter,  they 
are  plentiful.  In  addition  to  the  elements  already  described,  we 
find  often  two  varieties  of  crystals.  One  of  these  varieties,  which 


FIG.  62. — Normal  semen. 


FIG.  6 1. — a.  b.  c.  Pros- 
tatic  calculi  from  normal 
semen,  d.  Spermatozoa,  e. 
Large  and  small  cells,  some 
containing  granules,  as  mor- 
phological elements  of  se- 
men, f.  Spermatozoon  dis- 
torted by  imbibition  of 
water,  g.  Crystals.  (After 
Bizzozero.) 


appears  only  when  decomposition  is  far  advanced,  consists  of  am- 
monium magnesium  phosphate.  The  other  variety  has  a  chemical 
composition  not  yet  determined.  These  crystals  belong  to  the  mono- 
clinic  system,  forming  prisms  or  pyramids,  often  with  curved  sur- 
faces ;  they  are  colourless  or  light  yellow ;  they  lie  superimposed, 


312  THE  SEXUAL  LIFE  OF  WOMAN. 

often  forming  beautiful  star-shaped  figures.  They  are  soluble  in 
mineral  and  vegetable  acids,  and  in  ammonia,  but  are  insoluble  in 
alcohol,  ether,  and  chloroform ;  they  are  remarkably  resistent  to  the 
solvent  powers  of  cold  water,  but  not  so  to  those  of  boiling  water. 
Shreiner  has  proved  that  these  crystals  consist  of  a  phosphate  of  a 
base  which  is  represented  by  the  formula  C2.  H$.  N.  According  to 
Filrbringcr,  these  crystals  are  produced  as  a  result  of  the  action  of 
the  semen,  upon  the  prostatic  secretion. 

The  quantity  of  semen  ejaculated  during  coitus  is  very  variable, 
depending  upon  the  age  and  size  of  the  individual  and  the  formation 
of  his  testicles,  upon  his  individual  sexual  capacity,  and  upon  the 
question  whether  antecedently  there  has  been  sexual  excess  on  the 
one  hand  or  long  continued  continence  on  the  other.  In  general, 
the  quantity  of  semen  ejaculated  at  one  time  varies  between  0.75 
and  6  c.c.  (10  to  100  minims). 

If  healthy,  normal  semen,  with  adequate  fertilizing  potency,  is 
properly  preserved  from  cold  and  light,  we  may,  even  after  the 
lapse  of  twenty-four  hours,  find  under  the  microscope  spermatozoa 
still  engaged  in  active  movement.  Ultzmann  employs  for  the  de- 
scription of  a  drop  of  fresh  semen,  the  comparison  that  it  is  full  of 
movement,  "  like  a  stirred  up  ant-heap."  Influenced  by  the  whip- 
like  lashings  of  the  tail,  the  spermatozoon  moves  steadily  forwards, 
finding  its  way  through  the  narrowest  passages  on  the  microscopic 
field  without  striking  any  of  the  cellular  structures  that  may  lie  in 
its  path.  The  longer  the  semen  remains  under  observation,  the  less 
active  are  these  movements  of  the  spermatozoa,  for  after  ejacula- 
tion they  gradually  die,  exhibiting  after  death  an  extended,  or  at 
most  a  slightly  curved  tail ;  those  spermatozoa,  on  the  other  hand, 
that  were  dead  before  ejaculation,  have  the  tail  spirally  twisted, 
rolled  up,  or  acutely  bent.  In  the  case  of  spermatozoa  which  have 
been  destroyed  by  the  action  of  some  other  deleterious  secretion,  as 
by  urine  or  by  acid  vaginal  secretion,  such  a  condition  of  the  tail 
is  very  commonly  seen.  When  the  semen  is  treated  with  water,  the 
movements  of  the  spermatozoa  soon  cease,  and  the  ends  of  their 
tails  frequently  roll  up  to  form  loops.  By  the  addition,  however, 
of  concentrated  solutions  of  neutral  salts,  of  albumen,  of  urea,  etc., 
it  is  possible  to  reanimate  these  motionless  spermatozoa,  so  that 
they  once  more  are  seen  to  perform  active  movements.  Moderately 
concentrated  animal  secretions  of  an  alkaline  reaction  are  favourable 
to  the  motor  activity  of  the  spermatozoa,  whilst  on  the  other  hand 
dilute  and  acid  secretions,  such  as  urine,  acid  mucus  (including  the 


THE  SEXUAL  EPOCH  OF  THE  MENACME.  313 

acid  vaginal  mucus),  and  catarrhal  secretions,  even  when  alkaline 
in  reaction,  have  a  depressant  influence  on  this  activity.  Caustic 
potash  and  caustic  soda  stimulate  the  movements  of  the  sperma- 
tozoa. When  they  are  cooled  down  to  a  temperature  below  15°  C. 
(59°  F.),  the  movements  cease  entirely.  Salts  of  the  heavy  metals, 
and  mineral  acids  in  solution,  also  bring  their  movements  to  a  pause. 
Frequent  repetition  of  coitus  causes  a  diminution  in  the  number  and 
in  the  motor  activity  of  the  spermatozoa. 

Semen  which  contains  no  spermatozoa,  or  in  which  the  sperma- 
tozoa are  motionless,  is  absolutely  devoid  of  fertilizing  power;  in 
the  case  of  such  semen,  it  makes  no  difference  whatever  that  the 
external  genitals  of  the  man  generating  it  are  strongly  formed,  that 
his  testicles  are  of  normal  size,  and  that  erection  and  ejaculation 
take  place  promptly.  Of  very  little  value,  though  not  absolutely 
sterile,  is  semen  containing  very  few  living  spermatozoa,  or,  among 
very  numerous  motionless  spermatozoa,  containing  a  few  only  that 
are  engaged  in  active  movement.  Suspect,  is  semen  which  does 
not  possess  the  normal  light  greyish  white  tint,  but  is  brownish-red, 
brownish-yellow,  yellow,  or  violet;  these  variations  in  colour  indi- 
cating an  admixture  with  the  semen  of  varying  quantities  of  blood 
or  pus,  in  consequence  of  disease  of  the  urethra,  the  prostate,  the 
seminal  vesicles,  or  some  other  part  of  the  uropoietic  system ;  such 
admixtures  seriously  impair  the  quality  of  the  semen.  An  unfavour- 
able judgment  must  also  be  passed  on  semen  which,  at  each  suc- 
cessive ejaculation,  is  voided  in  very  small  quantities  only — from 
half  a  drachm  to  a  drachm.  When  thus  scanty,  semen  is  often 
found  to  contain  an  exceptionally  large  proportion  of  dead  sperma- 
tozoa. We  may  regard  very  favourably  semen  which  is  voided  in 
quantities  considerably  in  excess  of  the  average;  sometimes,  when 
there  is  a  veritable  polyspermia,  there  may  be  an  ounce  or  upwards, 
more  than  three  times  as  much  as  normal  —  provided,  of  course, 
that  this  semen  so  richly  voided  is  of  a  satisfactory  quality,  and 
contains  an  ample  proportion  of  active  spermatozoa.  The  most 
valuable  characteristic  in  semen  is  exhibited  when  the  spermatozoa 
it  contains  are  not  only  very  numerous  and  vigorously  active,  but 
when  they  are  also  very  long-lived,  when,  that  is  to  say,  they  retain 
the  power  of  active  movement  sometimes  for  as  long  as  three  days. 
A  decisive  opinion  as  to  the  quality  of  a  man's  semen  can  be  given 
only  as  the  result  of  precise  and  repeated  microscopic  examinations, 
and  the  medical  man  must  be  most  careful,  when  in  his  first  exami- 
nation he  has  not  been  able  to  detect  the  presence  of  any  living 


314  THE  SEXUAL  LIFE  OF  WOMAN. 

spermatozoa,  to  abstain  from  giving,  on  that  account  alone,  an  ad- 
verse decision  —  from  pronouncing  sentence  of  death  on  the  man's 
reproductive  potency. 

It  has  not  hitherto  been  accurately  determined  how  long  sperma- 
tozoa can  continue  to  live  in  the  interior  of  the  uterus,  although  the 
point  is  of  great  importance,  not  only  in  relation  to  conception,  but 
also  in  regard  to  the  theory  of  menstruation.  Percy  has  published 
a  case  in-  which,  eight  and  a  half  days  after  the  last  coitus,  he  saw 
living  spematozoa  emerge  from  the  os  uteri  externum.  Sims  bases 
upon  his  own  researches  the  decisive  opinion  that  in  the  vaginal 
mucus,  spermatozoa  can  never  survive  longer  than  twelve  hours, 
but  states  that  in  the  mucus  of  the  cervical  canal  they  can  live  much 
longer.  If  thirty-six  to  forty  hours  after  coitus,  we  examine  the 
cervical  mucus  under  the  microscope,  we  commonly  find  living  and 
dead  spermatozoa  in  about  equal  numbers.  Many  of  the  living  ones 
will  survive  their  removal  from  the  cervix  for  as  much  as  six  hours 
longer. 

Of  especial  interest  are  the  conditions  which  are  liable  to  deprive 
a  man  of  the  power  to  produce  fertilizing  semen.  In  the  first  place 
must  be  mentioned  congenital  absence  of  both  testicles  —  a  con- 
dition which,  in  otherwise  normally  formed  male  individuals,  is  one 
of  extreme  rarity.  Congenital  absence  of  one  testicle  is  less  rare, 
and  is  usually  accompanied  by  absence  also  of  the  epidydimis,  vas 
deferens,  and  seminal  vesicle  of  the  same  side.  The  potentia  ges- 
tendi  of  a  monorchid  depends  upon  the  proper  development  of  his 
single  testicle,  and  the  functional  capacity  of  this  organ  must  be  as- 
certained by  a  careful  microscopic  examination  of  his  semen.  Much 
more  frequent  than  absence  of  the  testicle,  though  still  sufficiently 
rare,  is  the  condition  of  cryptorchism,  non-descent  of  one  or  both 
testicles,  a  state  not  necessarily  associated  with  functional  incapacity 
of  the  organ.  Most  commonly,  however,  an  undescended  testis  is 
an  imperfectly  developed  testis,  and  in  the  very  great  majority  of 
cases  the  ejaculated  fluid  contains  no  spermatozoa. 

A  further  cause  of  the  lack  of  potent  semen  is  atrophy  of  the 
testicles  with  notable  diminution  in  the  size  of  the  glands,  and  more 
or  less  complete  disappearance  of  the  seminiferous  tubules  and  their 
cellular  contents.  This  state  is  rarely  congenital,  being  nearly  al- 
ways acquired :  in  consequence  of  inflammatory  conditions  affecting 
the  testicle  proper  or  the  epididymis  (syphilitic  inflammation, 
especially,  is  apt  to  lead  to  overgrowth  of  the  interstitial  connective 
tissue  and  to  gradual  destruction  by  pressure  of  the  seminal  tu- 


THE  SEXUAL  EPOCH  OF  THE  MENACME. 


315 


bules)*;  or  in  consequence  of  the  pressure  of  a  hernia,  a  varicocele, 
a  hydrocele,  or  a  tubercular,  carcinomatous,  or  other  new  growth ; 
or  in  consequence  of  constitutional  disorders,  especially  long-last- 
ing, severe,  and  exhausting  diseases,  such  as  diphtheria,  diabetes, 
or  chronic  alcoholism ;  in  consequence  of  diseases  affecting  that 
portion  of  the  central  nervous  system  from  which  the  nerves  sup- 
plying the  genital  organs  arise ;  in  consequence  of  degenerative 
changes  resulting  from  sexual  excesses ;  or,  finally,  in  consequence 
of  senile  changes,  such  as  fatty  changes  in  the  cells  of  the  semini- 
ferous tubules.  Certain  drugs  also,  digitalis,  salicylic  acid,  mercury, 
iodide  of  potassium,  arsenic,  and  morphine,  have  an  unfavourable 
influence  alike  on  the  quality  of  the  testicular  secretion  and  on  the 
potency  of  the  individual,  yon  Gyurkovechky  reports  that  in 
Bosnia  a  plant  locally  known  as.  "  neven  "  is  employed  among  the 
peasantry  for  the  temporary  suppression  of  sexual  potency,  wives 
giving  it  to  their  husbands  when  the  latter  are  about  to  leave  them 
and  go  upon  a  journey,  and  sprinkling  the  leaves  of  the  plant 
among  the  underclothing. 


FIG.  63 — Semen  consisting  chiefly  of  sperm-crystals,  cylindrical  spithclium 
and  small  granules  exhibiting  molecular  movement  —  but  containing  no 
spermatozoa. 

By  the  name  of  azoospermia  is  denoted  a  condition  whose  exist- 
ence can  be  determined  only  by  microscopic  examination. 

*  The  author  omits  special  reference  to  the  metastatic  orchids  that  so 
frequently  complicates  epidemic  parotitis  (mumps)  when  that  disease  occurs 
after  puberty.  Though  usually,  benign  in  character,  the  inflammation  very 
often  results  in  atrophy  of  the  testicle.  Fortunately,  bilateral  atrophy  from 
this  cause  is  very  rare;  and  even  when  it  does  occur,  both  testicles  being 
extremely  small,  potcntia  cocundi  and  potentia  gestandi  may  nevertheless 
remain.  But  when  double  atrophy  from  this  cause  takes  place  before 
puberty  (happily  an  occurrence  of  the  utmost  rarity),  sexual  development  is 
usually  arrested,  the  sufferer  being  in  effect  a  eunuch. —  TR. 


316  THE  SEXUAL  LIFE  OF 

The  subject  of  this  affection  has  normal  potentia  coeundi,  the 
semen  is  ejaculated  in  quite  normal  fashion,  and  it  is  its  constitu- 
tion only  that  is  faulty.  In  appearance  it  is  extremely  fluid,  and  is 
somewhat  cloudy;  its  sediment  contains  molecular  detritus  and 
spermatic  crystals,  but  no  spermatozoa  (Fig.  63).  If  the  medical 
man  makes  it  his  rule,  in  all  cases  in  which  he  is  consulted  on  ac- 
count of  sterility,  in  deciding  how  far  this  sterility  is  dependent  on 
the  condition  of  the  husband,  not  to  confine  himself  solely  to  the 
customary  questions,  whether  intercourse  is  regularly  practised, 
whether  before  or  after  menstruation,  etc. —  but  if  in  every  case  he 
makes  a  careful  examination  of  the  semen  under  the  microscope,  he 
will  be  astonished  to  learn  the  comparative  frequency  with  which 
he  will  note  the  complete  or  nearly  complete  absence  of  sperma- 
tozoa. This  condition  of  azoospermia  may  be  permanent  or 
transitory. 

To  Kehrer  belongs  the  credit  of  having  pointed  out  that  sterility 
is  less  often  due  to  impotence  or  to  aspermatism  than  to  azoo- 
spermia —  a  condition  often  unsuspected  by  husband  and  wife,  and 
one  to  be  diagnosed  by  the  physician  only  after  repeated  micro- 
scopic examinations  of  the  semen.  For  this  reason,  indeed,  its 
existence  is  often  overlooked.  Kehrer  believes  himself  to  be  justi- 
fied in  asserting  that  one-fourth  of  all  cases  of  sterility  (if  not 
indeed  more)  must  be  referred  to  conditions  affecting  the  husband, 
and  most  often  to  azoospermia ;  hence  he  concludes,  that  the  hus- 
band must  still  more  often  be  regarded  as  the  one  to  blame  for  the 
occurrence  of  sterility,  when  the  cases  are  borne  in  mind  in  which 
a  man  marries  with  an  imperfectly  healed  gonorrhoea,  and  infects 
his  wife,  giving  rise  to  a  chronic  tubo-uterine  blenorrhcea,  and  ulti- 
mately to  sealing  up  of  the  tubes  and  to  sterility. 

Complete  absence  or  marked  scarcity  of  spermatozoa  in  the 
semen  may  occur  also  without  any  change  in  the  testicle  that  can 
be  detected  by  an  external  examination,  as  a  consequence  of  con- 
tusions of  the  testicle,  or  of  gonorrhceal  inflammation  of  the  epididy- 
mis  or  vas  deferens;  further  as  a  sequel  of  severe  general  diseases, 
long-continued  physical  exertion,  or  great  sexual  excess. 

In  some  cases,  a  microscopical  examination  reveals,  not  azoo- 
spermia, but  oligozoospermia,  that  is  to  say,  the  number  of  living 
spermatozoa  in  the  semen  is  remarkably  small.  Or,  again,  the 
anomaly  may  be  of  this  character  that  the  spermatozoa  are  smaller 
than  normal,  that  they  are  motionless,  and  that  their  tails  are  broken 
off  —  such  are  the  peculiarities,  as  a  rule,  of  the  semen  of  old  men. 


THE  SEXUAL  EPOCH  OF  THE  MENACME. 


317 


A  less  common  condition  than  azoospermia,  but  one  the  patho- 
logical importance  of  which  is  equally  great,  is  aspermatism,  in 
which  the  man,  neither  during  coitus,  nor  in  any  other  form  of 
sexual  excitement,  is  able  to  ejaculate  any  semen.  This  condition 
may  be  congenital  or  acquired ;  it  may  be  permanent,  or  transitory 
(lasting  a  few  weeks  or  months).  In  these  cases  we  have  to  do 
with  organic  changes  in  the  testicles,  diseases  of  the  prostate, 
gonorrhceal  processes,  or  nervous  disturbances  resulting  in  a  loss 
of  irritability  in  the  reflex  centre  for  ejaculation.  Aspermatism  in 
the  narrower  sense  of  the  term,  a  condition,  that  is  to  say,  in  which 
there  is  total  suspension  of  the  activity  of  all  the  three  glands  which 
combine  to  secrete  the  composite  fluid  known  as  semen,  namely,  of 
the  testicle,  the  prostate,  and  the  seminal  vesicles  —  is,  according 
to  Filrbringer,  probably  non-existent.  The  pathological  state  un- 
derlying aspermatism  would  rather  appear  to  be,  not  a  failure  to 
secrete  semen,  but  a  failure  to  ejaculate  it. 

Last  of  all,  we  have  to  speak  of  conception  without  copulation, 
of  artificial  fertilization.  In  consequence  of  the  mechanical  hin- 
drances which  in  many  cases  prevent  the  entrance  of  the  semen  into 
the  interior  of  the  uterus,  the  idea  has  arisen  to  introduce  the  semen 
by  means  of  instruments  directly  into  the  cervical  canal,  dispensing 
with  the  natural  act  of  copulation.  Experience  long  ago  gained  in 


FIG.  64 — Oligozoospermia.    a.  Living  spermatozoa,    b.  Dead  spermatozoa, 
c.  Pus  corpuscles,  d.  Erythrocyte,    e.  Seminal  granules. 

artificial  pisciculture,  no  doubt  gave  rise  to  this  idea.  Spallanzani 
and  Rossi  by  means  of  a  syringe  injected  the  semen  of  a  dog  into 
the  vagina  of  a  bitch,  the  procedure  resulting  in  impregnation. 


318  THE  SEXUAL  LIFE  OF  WOMAN. 

Girault  appears  to  have  been  the  first,*  in  the  year  1838,  to  intro- 
duce semen  artifically  into  the  human  uterus,  if  we  leave  out  of  con- 
sideration the  experiment  of  Lesenrs,  who  introduced  a  tampon 
moistened  with  semen  into  the  interior  of  the  vagina.  The  proce- 
dure employed  by  Girault  is  thus  described:  The  patient  having 
been  placed  in  the  position  usually  employed  for  gynecological  ex- 
amination, a  canula  resembling  a  male  catheter  with  the  eye  in  its 
point,  and  with  a  funnel-shaped  enlargement  at  the  opposite  ex- 
tremity, is  introduced  into  the  uterus,  this  instrument  having  first 
been  prepared  by  moistening  its  interior  with  mucilage  and  filling 
it  with  semen;  by  insufflation,  the  semen  is  now  expelled  into  the 
uterine  cavity.  It  is  stated  that  neither  uterine  colic  nor  any  other 
dangerous  symptom  has  ever  been  brought  on  by  this  procedure. 
The  experiments  were  made  at  various  periods  between  the  year 
1838  and  the  year  1861 ;  they  were  ten  in  number,  and  of  these  eight 
proved  successful,  two  unsuccessful.  In  the  ten  cases,  the  total 
number  of  insufflations  made  was  twenty-one  —  the  minimum  num- 
ber in  any  single  case  being  one,  the  maximum  five.  In  one  case, 
the  insufflation  was  effected  immediately  after  the  cessation  of  men- 
struation ;  in  the  majority,  from  one  to  four  days  after  the  cessation 
of  menstruation ;  in  one  case  twelve  days,  in  one  case  twenty-three 
days,  after  the  cessation  of  the  flow.  Can  tier,  instead  of  insuffla- 
tions, has  employed  injections  of  semen,  using  two  injections  in 
each  case,  one  just  before  menstruation  was  expected,  the  other  a 
day  or  two  after  the  cessation  of  the  flow.  Marion  Sims  en- 
deavoured in  twenty-seven  cases  to  bring  about  conception  by  the 
injection  of  semen  into  the  uterus;  in  one  of  these  cases  only  was 
the  desired  result  obtained.  In  this  latter  instance  the  patient  was 
twenty-eight  years  of  age,  had  been  married  for  nine  years,  but  had 
remained  barren.  Throughout  her  menstrual  life,  she  had  suffered 
more  or  less  from  dysmenorrhoea,  often  accompanied  by  severe  con- 
stitutional disturbance,  such  as  syncope,  vomiting,  and  headache. 
Local  examination  disclosed  the  existence  of  retroversion  of  the 
uterus  with  hypertrophy  of  the  posterior  wall,  an  indurated,  conical 
cervix,  with  stricture  of  the  cervical  canal,  especially  in  the  region 
of  the  os  uteri  internum.  In  addition  to  all  these  mechanical  ob- 
stacles to  conception,  it  was  found  that  the  semen  was  never  retained 
in  the  vagina  after  coitus.  Sims  examined  the  patient  immediately 

*  It  is  recorded  of  John  Hunter  that  in  a  case  of  hypospadias,  he  advised 
the  patient  to  draw  his  semen  into  a  syringe  and  inject  it  into  his  wife's 
vagina,  with  fruitful  result.  TR. 


THE  SEXUAL  EPOCH  OF  THE  MENACME.  319 

after  coitus  had  taken  place,  but  never  found  a  single  drop  of  semen 
in  the  vagina,  notwithstanding  the  fact  that  this  fluid  had  been 
ejaculated  in  abundance.  Sim's  first  care  was  to  bring  about  reposi- 
tion of  the  uterus,  and  to  keep  the  organ  in  its  proper  place  by  the 
insertion  of  a  suitable  pessary.  Injections  of  semen  were  then  un- 
dertaken, and  were  continued  throughout  a  period  of  nearly  twelve 
months.  In  two  instances,  the  injection  was  effected  immediately 
before  the  onset  of  the  menstrual  flow ;  in  eight  instances  it  was 
effected  at  varying  times  (two  to  seven  days)  after  the  cessation 
of  the  flow.  At  first,  three  drops  of  semen  were  injected,  but  later 
only  half  a  drop.  The  semen  (first  ejaculated  into  the  vagina  dur- 
ing normal  intercourse)  was  injected  by  means  of  a  glass  syringe, 
which  was  kept  in  a  vessel  of  warm  water  at  a  temperature  of  98°  F. 
Since  during  the  removal  of  the  instrument  from  the  water  and  its  in- 
sertion into  the  vagina,  some  fall  in  temperature  necessarily  occurred 
in  the  vagina,  Sims  allowed  the  syringe  to  remain  for  some  minutes 
in  the  vagina  before  he  drew  the  semen  into  it,  in  order  that  he  might 
feel  assured  that  syringe  and  vagina  had  regained  the  tempera- 
ture most  adapted  to  the  vital  activity  of  the  spermatozoa.  The 
nozzle  of  the  syringe  was  then  carefully  introduced  into  the  cervical 
canal,  and  half  a  drop  of  semen  was  slowly  injected  into  the  uterine 
cavity.  For  two  or  three  hours  after  the  operation,  the  patient  re- 
mained lying  quiet  in  bed.  After  the  tenth  experiment,  conception 
ensued  —  the  first  recorded  case  of  artificial  fertilization  in  the 
human  species. 

With  right,  however,  this  case  of  Sim's  was  not  regarded  as  con- 
clusive, since  both  before  and  after  the  injection,  ordinary  coitus 
had  been  effected,  and  it  is  therefore  impossible  to  determine 
whether  the  fertilizing  spermatozoon  was  one  of  those  introduced 
by  means  of  the  syringe,  or  in  the  antecedent  or  subsequent  coitus  — 
more  especially  in  view  of  the  fact  that  by  the  insertion  of  a  pessary 
Sims  had,  previously  to  undertaking  the  injections,  restored  the 
uterus  to  a  position  more  suited  to  the  occurrence  of  conception  in 
the  natural  manner. 

In  a  case  which  a  priori  seemed  exceedingly  well  adapted  for 
the  performance  of  artificial  fertilization,  one  of  marked  hypospadias 
in  a  man  whose  semen  was  abundant  and  contained  a  large  number 
of  vigorously  moving  spermatozoa,  I  saw  this  experiment  fail,  in 
spite  of  all  possible  care  in  its  performance.  In  fact,  not  a  single 
conclusive  instance  of  successful  artificial  fertilization  in  the  human 
species  is  known  to  me,  though  I  have  seen  reports  of  numerous 


320  THE  SEXUAL  LIFE  OF  WOMAN. 

disagreeable  and  even  dangerous  results  of  attempts  to  effect  it. 
Both  parametritis  and  perimetritis  have  occurred  in  such  cases ;  and 
semen,  being  a  material  in  a  state  of  most  intense  molecular  move- 
ment, may  be  regarded  as  extremely  liable  to  noxious  transfor- 
mations. 

Sim's  procedure  has  been  modified  by  other  gynecologists.  Thus, 
Conrty's  plan  was  that  during  coitus  the  semen  should  be  collected 
in  a  condom,  fitting  not  too  closely,  from  which  receptacle  it  was 
drawn  up  into  a  syringe  and  carefully  injected  into  the  cervical 
canal.  Pa  jot's  plan  was  that  the  semen  should  be  ejaculated  into 
the  vagina  in  natural  coitus,  and  should  thence  be  pressed  into  the 
uterine  cavity  by  means  of  a  piston-like  instrument  introduced  into 
the  vagina. 

In  London,  Harley  frequently  made  the  experiment  of  injecting 
semen  into  the  uterine  cavity,  but  in  all  cases  without  any  result. 

P.  Muller,  in  two  cases,  on  account  of  extreme  anteflexion  of  the 
uterus,  performed  this  experiment.  Though  the  general  conditions 
were  in  both  cases  extremely  favourable,  in  neither  instance  was 
there  any  result.  It  must,  however,  be  mentioned  that  in  one  of 
his  cases  only  had  there  been  any  preliminary  examination  of  the 
semen  under  the  microscope. 

Fritsch  reports  a  case  in  which  gonorrhceal  secretion  was  injected 
in  place  of  semen.  Peritonitis,  which  for  a  month  endangered  life, 
was  the  result. 

In  Paris,  Lntaud  has  earnestly  advocated  artificial  impregnation 
in  cases  of  sterility  in  which  all  other  means  have  failed.  It  is 
obvious  that  it  would  be  useless  to  employ  this  measure  after  the 
menopause,  or  in  women  in  whom  menstrual  activity  has  ceased 
prematurely,  with  simultaneous  disappearance  of  all  menstrual 
molimina.  Equally  useless  would  it  be  in  uterine  atrophy  and  in 
cases  of  irremediable  malformation  of  the  female  genitals.  Further 
contra-indications,  according  to  Lntaud,  are  offered  by  chronic  pelvic 
peritonitis,  since  here,  on  account  of  the  obliteration  of  the  lumen 
of  the  Fallopian  tubes,  the  operation  is  foredoomed  to  failure. 
Chronic  inflammatory  states  of  the  uterus  and  its  mucous  mem- 
brane, will  also  render  the  attempt  useless.  Moreover,  it  is  a  con- 
dition indispensable  to  success  that  the  semen  to  be  employed  shall 
have  been  examined  microscopically,  and  shall  have  been  found  to 
be  thoroughly  healthy.  The  operation  has  the  greatest  prospect  of 
success  when  undertaken  from  three  to  two  days  before  the  due 
date  of  menstruation.  The  method  employed  is  that  of  Sims.  If 


THE  SEXUAL  EPOCH  OF  THE  MENACME.  321 

after  the  first  attempt,  the  due  menstruation  should  begin,  the  in- 
jection should  be  repeated  a  week  after  the  flow  has  ceased;  the 
attempt  should  not,  however,  be  repeated  more  than  about  six  times 
in  all,  since  the  probability  of  success  rapidly  diminishes  with  each 
successive  endeavour.  Before  the  operation  is  undertaken,  the  per- 
meability of  the  cervical  canal  must  be  ascertained.  Further,  in 
order  that  the  spermatozoa  shall  be  placed  in  conditions  in  which 
they  have  the  best  possible  chance  of  survival,  a  weak  alkaline  solu- 
tion, such  as  i  per  cent,  of  potassium  bicarbonate,  should  as  a  pre- 
liminary measure  be  injected  into  the  vagina. 

Lutand  thus  describes  the  procedure  he  employs.  Immediately 
after  the  woman  has  had  intercourse  with  her  husband,  a  Fergus- 
son's  speculum 'is  introduced  into  the  vagina,  the  patient  remaining 
in  the  dorsal  decubitus.  As  the  speculum  passes  in,  its  margin 
scrapes  the  surface  of  the  vagina,  and  by  this  means  the  semen  is 
collected  in  the  vicinity  of  the  cervix.  The  semen  is  then  drawn 
up  into  a  Pravaz  syringe  or  an  analogous  instrument,  such  as  a 
uterine  catheter  armed  at  one  end  with  a  rubber  ball.  The  fluid  is 
then  carefully  injected  into  the  cervical  canal,  or  preferably  into 
the  uterine  cavity,  great  care  being  taken  not  to  injure  the  mucous 
membrane  in  any  way,  since  the  slightest  bleeding  may  nullify  the 
whole  procedure.  Finally,  a  small  tampon  of  absorbent  cotton-wool 
is  inserted  into  the  os  uteri  externum.  For  some  hours  the  woman 
must  remain  quiet  in  bed ;  the  tampon  is  not  removed  for  ten  hours. 
As  regards  results,  Lutaud  informs  us  that  he  has  in  this  way  treated 
twenty-six  cases.  In  twenty-two  of  these,  failure  was  complete ;  in 
one  case,  success  was  partial  —  the  patient  was  impregnated,  but 
abortion  occurred  two  weeks  later;  in  another  case,  abortion  oc- 
curred after  three  months  pregnancy ;  finally,  in  two  cases,  success 
was  complete. 

Indications  for  the  employment  of  artificial  impregnation  are: 
first,  the  existence  of  stenosis  in  the  upper  part  of  the  cervical  canal, 
especially  stenosis  in  the  upper  part  of  the  cervical  canal,  especially 
stenosis  from  flexion,  provided,  of  course,  that  other  measures  are 
contra-indicated  or  have  been  fruitlessly  employed  ;  secondly,  a  dele- 
terious character  of  the  secretion  of  the  cervical  canal ;  thirdly,  ex- 
treme cases  of  hypospadias  in  the  male.  Haitssmann  recommends 
the  employment  of  artificial  impregnation  in  cases  in  which  the 
spermatozoa  are  found  to  enter  the  cervical  canal,  but  fail  to  pass 
through  the  os  uteri  internum.  Whilst  artificial  impregnation  is 
theoretically  a  sound  measure,  yet  in  the  practice  the  indications  for 

21 


322  THE  SEXUAL  LIFE  OF  WOMAN. 

its  performance  are  by  no  means  easy  to  establish.  For,  in  cases 
in  which  there  is  some  mechanical  hindrance  to  the  contact  of  the 
spermatozoon  with  the  ovum  (and  it  is  for  such  cases  only  that  this 
method  of  artificial  fertilization  can  properly  be  employed),  it  is 
often  extremely  difficult,  and  may  even  be  quite  impossible,  to  ex- 
clude the  possibility  of  there  being  some  failure  in  ovulation  itself, 
or  in  the  maturation  of  the  ova;  or,  again,  sterility  may  depend, 
not  on  the  fact  that  no  ova  are  fertilized,  but  on  the  fact  that  when 
fertilized  they  always  fail,  for  some  reason,  to  find  a  resting  place 
in  the  uterus;  in  a  word,  in  any  case  in  which  sterility  appears  to 
be  due  to  mechanical  obstacles  to  conception,  it  may  in  reality  be 
due  to  some  other  disease  which  has  escaped  recognition,  some 
organic  disease  of  the  uterus,  the  tubes,  the  ovaries,  of  the  peri- 
uterine  tissues. 

Finally,  it  must  be  remembered  that  the  manipulation  is  far  from 
easy  in  its  performance.  Above  all,  the  semen  must  be  subjected  to 
a  most  rigorous  microscopical  examination  in  respect  of  its  fertiliz- 
ing capacity.  But  this  examination  cannot  be  made  in  the  case  of 
the  semen  that  is  actually  used  for  the  attempt  at  artificial  fertiliza- 
tion ;  it  can  only  be  done  with  an  earlier  specimen  from  the  same 
man.  If  the  semen  contains  no  living  spermatozoa,  or  very  few 
only  and  these  sluggish  in  their  movements,  still  more  if  it  con- 
tains pus  corpuscles  or  gonococci,  all  idea  of  its  employment  for 
artificial  fertilization  must  be  rejected. 

The  method  employed  by  Sims,  in  which  the  semen  is  drawn  into 
a  syringe  inserted  into  the  vagina  post  coitum,  is  one  which  I  am 
not  able  to  recommend,  since  in  this  way  together  with  the  semen 
some  vaginal  mucus  is  drawn  up,  thus,  instead  of  pure  semen,  we 
inject  into  the  vagina  semen  mixed  with  various  impurities,  and 
more  especially  with  an  acid  secretion  known  to  be  unfavourable 
to  the  life  of  the  spermatozoa  —  a  circumstance  that  will  doubtless 
explain  many  of  the  failures  that  have  hitherto  taken  place.  It  is 
certainly  better  that  the  semen  of  the  husband  should  be  collected 
in  a  rubber  condom.  The  preservation  of  the  material  to  be  in- 
jected at  a  suitable  temperature  (the  normal  body-temperature),  is 
by  no  means  easy.  The  syringe,  an  ordinary  Braun's  uterine 
syringe,  is  first  disinfected,  and  then  lies  ready  in  water  of  the 
proper  temperature.  The  semen  is  rapidly  drawn  up  into  the 
syringe,  the  nozzle  of  which  is  then  passed  down  to  the  fundus 
uteri.  Quite  a  small  quantity  of  semen  will  suffice.  After  the 
manipulation,  which  should  of  course  be  undertaken  at  the  time  most 


THE  SEXUAL  EPOCH  OF  THE  MENACME.  323 

favourable  to  conception,  just  after  menstruation,  the  woman  should 
lie  quiet  in  bed  for  some  hours. 

In  considering  the  probability  of  a  successful  issue  to  any  such 
attempt  to  secure  artificial  fertilization,  we  cannot  leave  out  of  con- 
sideration the  likelihood  that  that  result  may  be  prejudiced  by  the 
lack  of  all  normal  sexual  feeling  on  the  part  of  the  wife ;  concerning 
the  significance  of  such  feeling  in  relation  to  the  sexual  act,  we  have 
however  as  yet  no  certain  knowledge. 

That  this  procedure  of  artificial  fertilization  is  extremely  dis- 
agreeable to  all  concerned  therein,  the  physician  not  excepted,  and 
that  various  moral  and  social  considerations  can  be  alleged  against 
it,  is  incontestable.  It  is  indeed  recorded  that  in  Bordeaux  a  legal 
penalty  was  inflicted  on  a  medical  man  who  undertook  to  bring 
about  artificial  fertilization.  The  Society  of  Medical  Jurists  debated 
this  matter,  and  came  to  the  conclusion  that,  whilst  a  medical  man 
was  not  justified  in  recommending  the  practice,  neither  was  he 
justified  in  refusing  to  undertake  it  when  requested  by  his  patients. 
In  Paris,  a  candidate  for  the  degree  of  Doctor  of  Medicine  made 
artificial  fecundation  the  subject  of  his  thesis,  and  maintained  that 
its  practice,  when  effected  with  all  proper  social  precautions  and  ac- 
cording to  scientific  principles,  was  possible,  reasonable,  useful,  and 
moral,  and  that  in  many  instances  it  should  be  recommended  by  the 
physician.  After  a  long  and  stormy  debate,  the  Faculty  of  Medi- 
cine determined  to  reject  the  thesis  and  to  destroy  all  specimens  of 
it  already  printed,  on  the  ground  that  "  they  feared,  if  they  gave 
their  sanction  to  the  practice,  that  a  number  of  more  or  less  un- 
scrupulous physicians  would  make  that  sanction  the  basis  of  im- 
proper practices,  dangerous  alike  to  the  family  and  to  the  state, 
since  the  operative  method  under  consideration  was  one  likely  to 
be  eagerly  exploited  by  the  whole  tribe  of  medical  charlatans."  This 
weighty  pronouncement  would  appear  to  be  sufficient  ground  for  re- 
jecting artificial  fecundation  as  a  matter  of  routine  practice ;  still, 
very  exceptional  cases  may  be  encountered  in  which  it  may  be  seized 
as  an  ultimum  refugium. 

Pathology  of  Copulation. 

The  act  of  copulation  may  be  interfered  with  or  entirely  prevented 
by  pathological  conditions  affecting  the  genital  canal  of  the  woman, 
and  also  by  disturbances  of  the  nervous  system  —  naturally  also  by 
any  abnormality  affecting  the  performance  of  the  male  partner  in 
the  act. 


THE  SEXUAL  LIFE  OF  WOMAN. 


Abnormality  of  the  hymen,  such  as  excessive  strength  and  rigid- 
ity, rendering  the  organ  unduly  persistent,  is  a  not  infrequent  hin- 
drance to  intercourse,  one  that  sometimes  is  not  overcome  even  after 
years  of  married  life;  to  such  a  state  of  affairs  ignorance  on  the  part 
of  the  married  pair  in  respect  to  the  proper  method  of  intercourse, 
lack  of  sufficient  sexual  power  on  the  part  of  the  male,  or  inflam- 
mation of  the  fossa  navicularis  brought  on  by  maladroit  attempts 
at  penetration,  may  contribute,  likewise  undue  passivity  on  the  part 
of  the  female  partner. 

A  notable  and  sometimes  an  insuperable  obstacle  (of  which  it  has 
been  written,  nee  Hannibal  qitidem  has  portas  perfringere  valuisset} 
is  constituted  by  that  abnormality  of  the  hymen  in  which  the  aper- 
ture in  that  membrane  is  guarded  by  a  sagittally  placed  or  sometimes 
oblique  septum,  dense  and  almost  tendinous  in  structure.  In  a 
woman  of  twenty-four  years,  who  for  two  years  had  lived  in  sterile 
wedlock,  I  found  such  a  tendinous  hymen  septum.  She  had  men- 
struated regularly  since  the  age  of  seventeen  years,  but  always  pain- 
fully. She  complained  that  her  husband  was  "  very  weak,"  inas- 
much as  on  her  bridal  night  he  was  unable  to  succeed  in  completing 
intercourse,  and  since  then  whenever  he  attempted  intercourse, 
premature  ejaculation  resulted,  before  penetration  of  the  penis 


FIG..  65. —  Septate  Hymen,  the  septum  having  a  tendinous  consistency.. 

had  been  effected.  In  consequence  of  this  repeated  inef- 
fectual sexual  excitement,  she  had  herself  become  very  nervous. 
On  local  examination,  I  found  an  elongated  oval  hymen,  not  com- 


THE  SEXUAL  EPOCH  OF  THE  MENACME.  325 

pletely  covering  the  vaginal  orifice,  rather  strong  and  thick,  and 
divided  in  two  halves  by  a  median  sagittal  septum,  of  a  densely 
tendinous  consistency.  On  either  side  of  the  septum,  the  vaginal 
orifice  would  admit  no  more  than  the  head  of  an  ordinary  uterine 
sound.  I  divided  this  septum,  and  was  informed  later  that  the 
woman  had  become  pregnant  as  a  result  of  the  first  subsequent  act 
of  intercourse  (Fig.  65). 

A  remarkable  case  of  abnormality  of  the  hymen  is  recorded  by 
Heitsmann,  having  been  observed  by  him  in  a  woman  aged  twenty- 
seven  years.  In  this  instance,  the  hymen  was  represented  by  a  swell- 
ing, smooth  on  the  surface  and  separated  from  the  nymphse  by  a 
deep  furrow.  Behind  this  swelling,  between  it  and  the  posterior 
commissure,  there  was  a  deep  depression,  into  which  the  finger 
could  be  passed  to  a  depth  of  an  inch  and  a  half  or  more.  Anteriorly, 
the  very  firm  and  fleshy  prominence  was  bounded  by  a  ridge,  from 
the -middle  of  which  to  the  urethral  orifice  ran  a  short  but  strong 
and  tense  septum.  Right  and  left  of  this  septum  were  small  aper- 
tures, with  difficulty  admitting  the  point  of  a  probe.  Between  the 
anterior  extermity  of  the  septum  and  the  urethral  orifice  was  a 
nodular  representative  of  the  swelling  normally  present  in  this  situa- 
tion. Surrounding  the  urethral  orifice  were  two  or  three  additional 
small  nodules.  The  two  lateral  margins  of  the  hymen  were  pro- 
longed around  the  urethral  orifice,  and  united  in  front  thereof  to 
form  a  raphe,  which  could  be  traced  as  far  as  the  base  of  the  clitoris. 
The  young  woman  had  been  married  for  some  months,  and  asserted 
that  she  had  repeatedly  had  intercourse.  With  such  a  condition  of 
the  female  genitals,  penetration  of  the  penis  into  the  vagina  was 
however  quite  impossible.  During  coitus,  the  penis  must  have  been 
inserted  into  the  aforesaid  depression  behind  the  swelling,  which 
was  sufficiently  extensible  for  the  purpose. 

A  less  serious  hindrance  to  intercourse,  but  one  more  frequently 
encountered,  is  a  partial  persistence  of  the  septum  of  the  hymeneal 
orifice,  in  such  a  manner  that  there  is  a  projecting  tongue  of  mem- 
brane from  the  anterior  and  posterior  margins  of  the  orifice, 
partially  blocking  this  latter ;  or  there  may  be  a  single  median  pro- 
jection only,  either  in  front  or  behind.  Such  processes  may  be  re- 
markable alike  for  their  size  and  their  shape.  Liman  describes  a 
cordiform  hymeneal  orifice,  constituted  by  an  anterior  or  posterior 
protection  of  the  kind  here  described. 

In  cases  of  imperforate  hymen  in  which  the  occlusion  of  the 
vagina  is  not  complete,  impregnation  may  in  rare  instances  occur, 


326 


THE  SEXUAL  LIFE  OF  WOMAN. 


even  though  proper  intromission  of  the  penis  is  quite  impossible. 
Cases  of  this  kind  have  been  observed  by  Scanzoni,  Horton,  K. 
Braun,  Leopold,  Brille,  Breisky,  and  others. 


FIG.  66. 

In  most  of  these  cases  there  was  a  thick,  dense,  "  imperforate," 
or  rather  persistent  hymen,  with  an  orifice  no  larger  than  the  head 
of  an  ordinary  probe,  notwithstanding  which  pregnancy  had  oc- 
curred. The  cases  reported  by  Brill  were  of  a  different  character, 
being  those  of  two  young  unmarried  Russian  girls,  with  normal 
undestroyed  hymens,  who  were  found  to  be  pregnant.  According 
to  Brill,  such  cases  are  by  no  means  uncommon  among  the  peasantry 
of  Little  Russia,  where  the  barbarous  practice  prevails  of  adolescent 
girls  and  boys  sleeping  together.  In  these  circumstances,  sexual  in- 
tercourse takes  place,  but,  from  fear  of  consequences,  it  is  often 
incomplete.  Hence,  in  occasional  cases,  results  pregnancy  in  a 
young  girl  with  intact  hymen. 

In  the  first  complete  act  of  intercourse,  the  defloration  of  the 
virgin,  the  hymen  is  as  a  rule  torn  in  several  directions,  and  in 
consequence  there  is  usually  moderate  bleeding.  The  lacerations  of 


THE  SEXUAL  EPOCH  OF  THE  MENACME.  327" 

the  hymen  soon  skin  over.  When  the  initial  coitus  is  effected  mala- 
droitly  or  roughly,  more  extensive  lacerations  are  apt  to  occur,  and 
the  injury  may  not  be  limited  to  the  hymen,  but  may  extend  longi- 
tudinally along  the  vaginal  wall,  and  even  involve  the  posterior 
vaginal  fornix.  Or,  again,  without  any  such  extensive  laceration, 
there  may  result  very  profuse  bleeding,  in  consequence  of  abnor- 
mally profuse;  vascularization  of  the  hymen.  Cases  are  also  re- 
corded in  which  (presumably  not  from  normal  coitus  alone,  but 
from  other,  unacknowledged  manipulations),  whilst  the  hymen  has 
been  left  intact,  false  passages  have  been  made,  leading  to  the  for- 
mation of  fistulae,  with  subsequent  death  from  haemorrhage  or 
sepsis. 

Apart  from  impotence  in  the  male,  the  hymen  may  remain  intact 
when  it  is  not  touched  at  all  during  coitus.  Inexperience,  as  Veit 
remarks,  will  in  this  matter  lead  to  results  almost  incredible.  This 
author  has  been  informed  by  such  inexperienced  married  couples, 
that  in  attempts  at  intercourse  "  the  penis  of  the  man  is  introduced 
between  the  thighs  of  the  woman,  which  are  closely  pressed  to- 
gether, the  man  having  his  legs  on  either  side.  Naturally,  in  this 
method  of  intercourse,  the  hymen  escapes  destruction.  In  such  at- 
tempts at  coitus,  things  are  done  which  can  hardly  be  compared  with 
the  normal  act  of  copulation." 

In  isolated  instances,  the  introduction  of  the  penis  is  prevented  by 
congenital  or  acquired  defects  in  the  formation  of  the  external 
genitals.  Adhesion  between  the  labia  majora  and  the  labia  minora 
i.<  sometimes  met  with  a  congenital  deformity,  which  may  or  may 
not  be  associated  with  atresia  of  the  urethral  orifice ;  in  some  cases 
the  adhesion  is  dependent  merely  upon  a  superficial  epithelial  con- 
tinuity, but  in  others  the  labia  are  firmly  adherent  throughout. 
Less  rare  are  acquired  adhesions,  the  result  of  accident,  between 
the  labia  majora  and  the  labia  minora,  leading  to  atresia  of  the 
vulva,  and  thus  making  copulation  impossible. 

Intromission  of  the  penis  may  be  rendered  quite  impossible  by 
excessive  size  of  the  labia  majora,  consequent  upon  elephantiasis, 
in  which  disease  there  is  enormous  hypertrophy  of  the  subcutaneous 
connective  tissue.  New  growths  may  have  the  same  result,  fibroids, 
for  instance,  lipomata,  and  cysts,  which  may  attain  a  remarkable 
size  in  the  cellular  tissue  of  the  labia,  the  mons  veneris,  and  the 
perineum,  and  also  in  the  nymphae  and  in  the  cellular  tissue  be- 
tween the  clitoris  and  the  urethral  orifice.  In  a  very  obese  woman 
twenty-eight  years  of  age  I  saw  a  lipoma  attached  to  the  right 


328  THE  SEXUAL  LIFE  OF  WOMAN. 

labium  majus.  In  the  course  of  six  years  it  had  grown  to  such  an 
enormous  size,  that  it  extended  downwards  over  the  thigh,  blocked 
the  entrance  to  the  vagina,  and  made  coitus  absolutely  impossible 


FIG.  67. —  Lipoma  of  the  right  labium  majus,  occluding  the  vaginal  inlet. 


(Fig.  67).     Various  forms  of  labial  hernia  are  also  competent  to 
occlude  the  vaginal  orifice. 

Hypertrophy  of  the  nymphae,  which,  as  the  so-called  Hottentot 
Apron  has  to  be  regarded  as  a  racial  peculiarity,  is  known  also  in 
Europe  as  a  pathological  condition  which  may  at  times  constitute  a 
hindrance  to  sexual  intercourse  (Fig.  68).  According  to  Otto  there 
are  three  fundamental  forms  of  the  Hottentot  apron,  viz.,  excessive 
enlargement  of  the  nymphae,  overgrowth  of  the  labia  majora,  and, 
lastly,  the  formation  of  a  peculiar  lobe  of  flesh  and  skin,  attached 
to  the  mons  veneris  by  a  pedicle,  containing  the  clitoris,  and  cover- 
ing the  genital  fissure  as  with  a  valve.  Hypertrophy  of  the  nymphae 
is  said  to  be  common  also  in  Turkish  and  in  Persian  women.  Ow- 
ing to  the  obstacle  to  intercourse  presented  by  hypertrophied 
nymphae,  it  is  among  certain  races  an  established  custom  to  ampu- 
tate clitoris  and  nymphae  together.  Virey  writes :  "  The  Portuguese 
Jesuit  missionaries  to  Abyssinia  in  the  sixteenth  century,  en- 
deavoured to  abolish  this  practice  of  the  circumcision  of  women, 
which  they  regarded  as  a  relic  of  Mohammedanism ;  the  uncircum- 
cised  maidens,  however,  could  find  no  husbands,  owing  to  the  in- 
convenient length  of  their  nymphae.  The  pope  sent  surgeons 


329 

to  the  country,  to  enquire  into  the  matter,  and  their  reports  were  in 
such  sense  that  circumcision  was  permitted  as  necessary."  Davis 
reports  observations  made  by  Sonini  on  the  female  indigens  of 


FIG.  68. — "  Hottentot  apron  "  in  an  adult  woman,  hanging  down  between 
the  thighs.     (After  Zweifel.) 

lower  Egypt,  in  whom  the  vulva  hangs  down  in  the  form  of  a  loose, 
flabby  mass  of  flesh,  of  striking  length  and  thickness,  completely 
covering  the  genital  fissure.  He  believes  that  the  circumcision  that 
was  practised  on  the  women  of  ancient  Egypt  consisted  in  the  re- 
moval of  this  hypertrophied  vulva. 

Courty  saw  a  case  in  which  the  remarkable  length  of  the  labia 
minora,  which  when  an  attempt  was  made  to  introduce  the  penis, 
covered  the  vaginal  orifice,  had  rendered  coitus  ineffective,  and  had 


330 


THE  SEXUAL  LIFE  OF  WOMAN. 


caused  sterility  for  five  years.     Resection  of  the  labia  minora  was 
followed  by  successful  intercourse  and  conception. 

The  lipomatous  form,  especially,  of  elephantiasis  vulvae  often 
attains  a  gigantic  size.  Growths  of  this  nature,  of  the  size  of  a 
child's  head,  weighing  six  or  seven  kilo  (thirteen  to  fifteen  pounds), 
and  reaching  down  to  below  the  knee,  are  by  no  means  rare.  I 
have  known  several  cases  in  which  an  excessive  accumulation  of 
fat  in  the"  vulva  associated  with  pendulous  belly  has  constituted  a 
mechanical  obstacle  to  the  completion  of  sexual  intercourse. 


FIG.  69. —  Elephantiasis  of  the  labia  majora 

Hypertrophy  of  the  clitoris  may  constitute  an  obstacle  to  coitus. 
In  exceptional  cases,  this  organ  is  as  large  as  the  male  penis,  and 
hangs  down  over  the  genital  fissure  like  a  valve.  Hyrtl  relates  that 
in  certain  African  races,  this  congenital  enlargement  of  the  clitoris 
is  so  enormous,  that  the  organ,  made  fast  to  the  perineum  with 
rings,  serves  for  the  protection  of  virginity.  Schonfcld  describes 
the  case  of  a  woman  aged  twenty-eight  years,  in  whom  the  vaginal 
orifice  was  almost  completely  occluded  by  a  dry  and  firm  growth, 
with  a  granulated  surface.  Close  observation  proved  this  growth 
to  be  produced  by  a  hypertrophied  and  degenerated  clitoris,  which 
had  attained  the  size  of  a  child's  head.  Elephantiasis  of  the  clitoris 


THE  SEXUAL  EPOCH  OF  THE  MENACME.  331 

is  especially  inconvenient  in  consequence  of  the  hindrance  which  the 
enlarged  organ  offers  to  sexual  intercourse.  Bainbridge  describes 
a  case  of  tumour  of  the  clitoris  measuring  8  cm.  (3.2  in.)  in  length 
and  5  cm.  (2  in.)  in  width.  The.  following  remarkable  case  is  re- 
corded by  Oesterlen:  A  young  man  wished  to  break  off  his  engage- 
ment on  the  ground  that  his  intended  wife  was  a  hermaphrodite. 
Examination,  however,  disclosed  the  existence  of  a  strong  intact 
hymen,  a  very  large  clitoris,  and  pregnancy  of  the  twentieth  week. 

Injuries  of  the  vagina  resulting  from  coitus  are,  generally  speak- 
ing, rare.  The  usual  cause  of  such  injuries  is  disproportion  in  size 
between  the  erect  penis  and  the  calibre  of  the  vagina,  or  else  brutal 
violence  in  the  performance  of  coitus ;  sometimes,  however,  it  is  de- 
pendent on  the  pathological  state  of  the  female  genital  organs,  which 
have  undergone  senile  atrophy. 

To  the  first  group  belongs  the  case  reported  by  Albert,  in  which 
a  girl  of  eleven  years  was  found  to  have  a  laceration  of  the  vagina 
communicating  with  the  peritoneal  cavity,  the  injury  resulting  from 
coitus.  To  the  second  group  belongs  the  case  reported  by  Bohm, 
of  lacerations  of  the  vaginal  mucous  membrane  resulting  from 
forcible  coitus  in  elderly  women.  E.  Frank  reports  a  case  of  injury 
due  to  violent  coitus  in  a  woman  in  whom  the  vagina  was  already 
greatly  stretched  by  retroflexion;  and  another  case  in  which  injury 
occurred  during  intercourse  in  a  woman  with  vagina  duplex  —  in 
this  case,  not  only  was  the  hymen  of  the  right  vagina  torn,  but  also 
the  septum  between  the  two  vaginae. 

By  no  means  extremely  rare  are  injuries  to  the  vagina  in  the 
act  of  defloration,  causing  severe  hemorrhage.  Martin  records  a 
fatal  case  of  this  nature.  Maschka  and  Hofmann,  the  authorities 
on  Forensic  Medicine,  deny  that  vaginal  laceration  is  the  result  of 
simple  coitus,  and  Hofmann  maintains  that  such  serious  injury  can 
occur  only  from  digital  manipulations ;  in  fact,  these  writers  believe 
that  the  penis  alone  cannot  be  employed  with  sufficient  force  to 
cause  laceration.  Barthel  and  Anderson,  however,  saw  vaginal 
lacerations  in  nulliparous  women  ;  and  Zeis  records  a  case  of  vaginal 
laceration  in  a  woman  twenty-five  years  of  age,  with  whom,  six 
weeks  after  parturition,  her  husband,  then  in  a  state  of  intoxication, 
had  had  intercourse  in  the  position  a  la  vache. 

Anomalies  of  the  vagina,  absence,  stricture,  duplication,  and  ab- 
normal apertures,  also  diseases  of  the  vaginal  tissues,  may  induce 
incapacity  for  sexual  intercourse.  In  frequency  as  in  significance, 
among  these  disorders,  absence  of  the  vagina  and  stenosis  and  atresia 


332  THE  SEXUAL  LIFE  OF  WOMAN. 

of  the  canal,  stand  in  the  first  rank.  Congenital  atresia  may  be 
complete  or  only  partial,  according  as  the  two  ducts  of  Midler  from 
the  fusion  of  which  the  tube  is  formed,  remain  totally  or  only  par- 
tially solid  —  or,  having  duly  canalized,  subsequently,  by  a  foetal 
inflammatory  process,  become  transformed  into  a  thick,  more  or  less 
solid  cord.  If  the  obliteration  of  the  vagina  is  at  the  lower  extrem- 
ity of  the  canal,  coitus  is  impossible,  unless,  as  sometimes  happens, 
by  frequent  attempts  at  intercourse,  the  short  blind  sac  representing 
the  lower  end  of  the  vagina  has  been  stretched  upwards  in  the  form 
of  a  pouch.  When  the  obliteration  of  the  ducts  of  Midler  is  complete, 
we  have  total  atresia  of  the  vagina,  in  which  case  the  uterus  is  also 
as  a  rule  wanting,  or  is  but  imperfectly  represented.  In  some  cases, 
from  the  ducts  of  Miillcr,  instead  of  the  normal  vagina,  there  is 
formed  a  tract  of  membrane  of  varying  density  and  width,  through 
which  passes  a  small  canal  for  the  passage  of  the  menstrual  dis- 
charge ;  this  condition  is  known  as  atresia  vaginalis  membranacea. 

When,  notwithstanding  malformation  of  the  external  genital 
organs  and  partial  absence  of  the  vagina,  there  is  no  defect  in  the 
internal  genital  organs,  conceptions  may  sometimes  be  effected 
through  some  abnormal  channel,  as  for  instance  through  a  communi- 
cation established  per  anum ;  or,  again,  some  operative  procedure 
may  bring  relief.  Rossi  reports  a  case  of  congenital  absence  of  the 
external  genital  organs,  in  which  an  incision  was  made  in  the  region 
of  the  absent  vagina,  and  an  artificial  vagina  was  thus  constructed ; 
copulation  was  in  this  way  rendered  possible,  and  conception  ensued. 
In  this  connection,  we  may  turn  with  interest  to  the  essay  by  Louis, 
entitled  Deficiente  Vagina,  Possuntne  per  Rectum  Concipere  Mit- 
lieresf  Here  we  are  told  of  a  case  in  which  vulva  and  vagina  were 
absent,  and  there  was  a  monthly  discharge  of  blood  per  anum ;  the 
woman's  lover  employed  this  passage  also  ad  immissionem  penis, 
and  the  woman  became  pregnant.  Pope  Benedict  XIV  expressly 
allowed  to  women  suffering  from  imperforatio  vaginae  the  practice 
of  coitus  parte  posteriori. 

Further,  in  cases  of  atresia  vaginae  in  which  the  genital  canal 
terminates  in  the  urethra,  conception  can  result  from  urethral  coitus, 
as  is  proved  by  cases  recorded  by  K.  von  Braun,  Weinbaiiin,  and 
Wyder.  In  Weinbanm's  case,  the  obliteration  of  the  vagina  was 
complete,  neither  eye  nor  finger  could  detect  the  slightest  aperture ; 
the  woman  having  become  pregnant  after  coitus  per  nrethram,  de- 
livery was  effected  by  Caesarian  section.  In  Wyder' s  case,  the  vagi- 
nal orifice  was  closed,  with  the  exception  of  a  minute  aperture,  by 


THE  SEXUAL  EPOCH  OF  THE  MENACME.  333 

means  of  dense  fibrous  tissue;  the  woman  was  in  labour  and  the 
head  of  the  child  was  in  the  pelvis.  Under  anaesthesia,  the  septum, 
which  was  nearly  an  inch  thick,  was  divided,  the  opening  was  en- 
larged, and  the  child  was  extracted  by  forceps.  An  investigation 
disclosed  that  the  husband  had  always  had  intercourse  by  introduc- 
ing his  penis  into  the  dilated  urethra ;  it  was  evident  that  the  semen 
had  passed  through  the  urethra  into  the  bladder,  and  thence  had 
found  its  way  through  a  vesico-vaginal  fistula  into  the  vagina  and 
uterus. 

Acquired  obliteration  and  stricture  of  the  vagina  from  the  con- 
traction of  scar  tissue,  in  consequence  of  deep  ulceration,  especially 
when  croupous  or  diphtheritic  in  nature,  following  typhus  or  ty- 
phoid, pyaemia,  puerperal  sepsis,  and  the  acute  exanthemata 
(especially  variola) — may  likewise  serve  as  obstacles  to  coitus. 
Syphilitic  affections  also,  through  contraction  of  exudations,  the  ad- 
hesion of  ulcerated  opposing  surfaces,  condylomata,  etc.,  may  give 
rise  to  stricture  or  obliteration  of  the  vagina.  The  same  conditions 
may  be  induced  by  trauma,  as  by  wounds,  by  attempts  at  rape,  or 
by  the  use  of  caustic  acids  and  alkalis. 

Thus,  Ahlfeld  saw  severe  stricture  of  the  vagina  as  a  sequel  of 
the  excision  of  four  large  condylomata.  Hennig  the  same,  after 
variola,  and  again  in  lunatics  who  had  introduced  caustic  fluids  into 
the  vagina.  By  L.  Mayer,  atresia  vaginae  was  seen  as  a  sequel 
of  typhoid ;  by  Weiss  as  a  sequel  of  diphtheria ;  by  Martin  from 
the  action  of  irritant  secretions  in  cases  of  uterine  tumour;  by 
Billroth  as  a  result  of  continued  irrigation  of  the  vagina  with  alka- 
line urine  after  lithotomy  or  urethrotomy,  and  in  cases  of  vesico- 
vaginal  fistula.  Ulcerative  processes  set  up  by  the  long  continued 
action  of  a  vaginal  tampon,  a  pessary,  or  some  other  foreign  body, 
have  been  noted  as  leading  to  consecutive  obliteration  of  the  vagina. 

Such  stenosis,  when  partial  only,  may  prevent  complete  coitus, 
and  yet  allow  conception  to  occur.  Cases  illustrating  this  fact  have 
been  numerously  recorded.  Thus,  van  S^vieten  already  reported  the 
case  of  a  girl  aged  sixteen  years,  whose  vagina  was  strictured  to 
such  an  extent  that  the  passage  would  barely  admit  a  crow-quill; 
nevertheless  she  became  pregnant,  and  was  successfully  delivered. 
Similar  cases  are  mentioned  by  von  Scansoni,  Kennedy,  Devilliers, 
Varge,  Moreau,  and  Plenk. 

Serious  obstacles  to  coitus,  of  a  nature  analogous  to  acquired 
stenosis  of  the  vagina,  are  constituted  by  the  irregular  ligamentous 
bridges  which  sometimes  arise  in  the  vagina  from  the  adhesion  of  a 


334  THE  SEXUAL  LIFE  OF  WOMAN. 

strip  torn  from  the  mucous  membrane  on  one  side  of  the  vagina  to 
the  other  side  of  that  tube  —  or,  again,  a  portion  of  a  lacerated 
cervix  may  adhere  to  the  wall  of  the  vagina.  An  interesting  case 
of  this  nature  came  under  my  own  observation.  It  was  a  woman 
aged  thirty-two  years,  who  had  twice  had  difficult  deliveries,  the 
last  time  nine  years  before.  Since  then  she  had  been  barren.  On 
local  examination  I  found  in  the  vagina  a  fleshy  bridge,  about  4  cm. 
(1.6  in.)  wide  and  6  cm.  (2.4  in.)  long,  extending  from  the  left 
side  of  the  portio  vaginalis  to  the  right  wall  of  the  vagina;  this 
mass  of  tissue  was  so  placed  that  the  intromitted  penis  must  neces- 
sarily have  slipped  past  it  into  a  blind  sac,  such  as  the  French  name 
tine  poche  copulatrice.  Similar  membranes  in  the  vagina  have  been 
described  by  Breisky,  Murphy,  and  Thomson. 

Various  tumours  may  narrow  or  even  completely  close  the  vaginal 
passage,  myoma,  sarcoma,  carcinoma,  and  especially  the  polypoid 
form  of  fibro-myoma,  which  may  even  project  without  the  vaginal 
orifice.  And  even  when  tumours  of  or  in  the  vagina  do  not  actually 
hinder  coitus  by  the  space  they  occupy,  they  may  affect  that  opera- 
tion by  bleeding  whenever  it  is  undertaken,  a  manifestation  ex- 
tremely alarming  to  young  married  persons. 

The  vagina  may  also  be  partially  occupied,  and  coitus  may  be 
impeded,  by  elongation  of  the  hypertrophied  cervix  uteri,  by  inver- 
sion or  prolapse  of  the  uterus,  by  cyctocele  or  rectocele,  and  by 
uterine  polypi.  Horuntz  records  the  case  of  a  woman  aged  twenty- 
two  years  in  whom  impotentia  coeundi  was  dependent  upon  the 
occlusion  of  the  vaginal  orifice  by  a  rounded,  strongly  projecting 
body,  which  proved  on  closer  examination  to  be  a  hypertrophied 
vaginal  bulb. 

Tumours  of  the  rectum  and  other  intra-pelvic  growths  may  en- 
croach upon  the  vaginal  passage  and  impede  coitus.  Closure  of  the 
vagina  has  been  brought  about  even  by  abnormal  size  and  abnormal 
toughness  of  the  perineum. 

Finally,  in  extreme  degrees  of  pelvic  contraction,  the  vagina  may 
be  so  much  narrowed  as  to  interfere  with  coitus.  Von  Hofmann 
records  a  case  of  this  nature:  In  a  woman  thirty  years  of  age, 
affected  with  kypho-scoliosis,  who  suffered  extreme  pain  whenever 
her  husband  attempted  sexual  intercourse,  the  pelvis  was  twisted 
and  narrowed  to  such  an  extent  that  the  conjugate  measured  barely 
one  inch,  and  the  vagina  was  so  small  as  barely  to  admit  the  finger. 

Duplication  of  the  vagina  will  constitute  an  obstacle  to  coitus 
when  both  halves  of  the  passage  are  too  narrow  to  allow  of  intro- 


THE  SEXUAL  EPOCH  OF  THE  MENACME.  335 

mission  of  the  penis.  Difficulty  in  intercourse  will  also  be  caused 
by  abnormal  termination  of  the  vagina,  as  by  its  termination  in  the 
rectum,  likewise  by  severe  perineal  laceration  which  has  converted 
the  lower  parts  of  the  vagina  and  rectum  into  a  cloaca,  likewise  by 
recto-vaginal  and  vesico-vaginal  fistulae;  in  the  case  of  all  these 
latter  states  a  feeling  of  disgust  is  apt  to  be  aroused  in  the  male 
which  may  effectually  check  sexual  desire.  Still,  coitus,  and  even 
conception,  are  quite  possible  in  these  conditions.  Kroner,  among 
sixty  cases  of  vaginal  fistula,  observed  six  in  which  conception  took 
place  while  the  fistula  was  actually  open. 

Apart  from  all  local  pathological  conditions,  coitus  may  be  inter- 
fered with  by  general  nervous  disturbances,  manifesting  themselves 
locally,  and  depriving  the  woman  so  affected  of  potentia  coeundi. 
First  among  such  states  must  be  mentioned  vaginismus,  a  condition 
so  important  as  to  demand  discussion  in  a  separate  chapter. 

An  important  and  by  no  means  rare  obstacle  to  the  completion 
of  intercourse,  affecting  the  male  partner  in  the  act,  is  partial  or  com- 
plete incapacity  for  erection  of  the  penis.  Even  excessive  smallness 
of  the  penis  may  render  coitus  inadequate ;  still  more  so,  however, 
organic  diseases  of  the  membrum,  such  as  obliteration  of  the  cor- 
pora cavernosa,  or  of  some  of  the  trabecular  channels  of  these 
bodies,  nodular  formations  resulting  from  injury,  or  cavernitis  from 
gonorrhoea.  In  such  cases,  erection  is  extremely  irregular,  and 
the  erect  penis  is  sharply  bent  (chordee)  instead  of  being  straight, 
a  condition  which  renders  intromission  mechanically  difficult  if  not 
impossible.  A  similar  effect  is  produced  by  ossification  of  some  part 
of  the  tunica  albuginea  of  the  corpora  cavernosa  —  the  so-called 
penis  bone.  Mechanical  obstacles  to  coitus  are  also  offered  by  in- 
guinal and  scrotal  hernias ;  and  by  excessive  obesity,  where  the 
increase  in  thickness  of  the  panniculus  adiposus  of  the  abdominal 
wall  and  the  mons  pubis,  whilst  the  penis  itself  remains  as  slender 
as  before,  causes  the  organ  almost  to  disappear  from  view. 

Psychical  impotence  in  the  male  is  much  more  frequently  observed 
than  organic  impotence.  We  meet  with  this  condition  especially  in 
neurasthenically  predisposed  individuals,  or  in  men  who  have  been 
given  to  excessive  venery  or  have  masturbated  excessively  in  youth, 
and  who,  when  entering  upon  married  life,  fear  they  will  be  unable 
to  satisfy  the  legitimate  desires  of  their  wives ;  or  in  newly  married 
men  who  have  suffered  often  from  gonorrhoeal  inflammations,  such 
as  prostatitis,  vesical  catarrh,  and  epididymitis.  The  fear  and  anxi- 
ety from  which  such  persons  suffer  has  an  inhibitory  influence  upon 


336  THE  SEXUAL  LIFE  OF  WOMAN. 

the  erection  of  the  penis.  In  some  instances,  this  inhibitory  influence 
is  partial  only,  and  the  man  thus  affected,  while  perfectly  competent 
in  intercourse  with  a  prostitute,  who  employs  means  of  sexual 
stimulation  to  which  he  has  become  accustomed,  is  unable  to  com- 
plete intercourse  with  his  wife,  who  is  ignorant  and  innocent,  and 
assumes  a  purely  passive  role ;  or  it  may  be  that  erection  is  not  suffi- 
ciently powerful  to  bring  about  rupture  of  the  hymen,  and  thus  to 
overcome  the  difficulties  primac  noctis. 

As  regards  gonorrhoeal  infection,  it  appears  that  in  men  who  in 
other  respects  are  perfectly  competent,  this  disease  has  an  inhibi- 
tory influence  upon  the  nervous  mechanism  concerned  in  producing 
erection  of  the  penis. 

Psychical  impotence  is  usually  transitory,  but  it  may  endure  for 
a  very  long  time ;  and  it  may  be  many  months  before  the  husband, 
whose  nervousness  has  led  to  failure  in  the  decisive  moment  at  the 
outset  of  married  life,  is  able  to  command  an  erection  sufficiently 
powerful  to  bring  about  the  defloration  of  his  \vife.  Occasionally 
such  psychical  impotence  is  not  absolute  but  relative,  it  relates,  that 
is  to  say,  to  one  particular  woman  —  unfortunately,  as  a  rule,  a 
man's  own  lawful  wife, —  whilst  coitus  with  another  woman,  even 
in  default  of  any  measures  for  artificial  sexual  stimulation,  is  easily 
effected.  This  fatal  misfortune  is  especially  liable  to  occur  in  cases 
in  w-hich  a  man  fully  experienced  in  sexual  matters  marries  a  woman 
whom  he  dislikes  or  for  whom  he  has  no  regard,  the  marriage  being 
determined  by  material  considerations.  From  such  women  I  have 
heard  the  painful  confession  that  the  husband,  a  man  renowned  for 
his  gallantries,  played  a  very  poor  part  in  the  bridal  bed. 

The  impotence  of  irritable  weakness  is  characterized  by  pre- 
mature, and  therefore  fruitless  ejaculation.  A  man  thus  affected 
has  a  powerful  erection  of  the  penis,  preparatory  to  coitus,  but  at 
the  moment  of  contact  with  the  female  genital  organs,  before  there 
has  been  time  for  penetration  to  occur,  ejaculation  takes  place,  and 
is  immediately  followed  by  relaxation  of  the  penis.  Such  irritative 
impotence  is  often  met  with  in  young  men  at  the  outset  of  their 
sexual  career,  in  beginners,  whose  sexual  passion  is  very  readily  ex- 
cited, \vhose  imagination  shoots  forward  to  the  goal,  and  who  are 
unable  to  restrain  themselves.  This  form  of  impotence  can  also  be 
cured  by  wisely  chosen  measures. 

The  paralytic  form  of  impotence,  on  the  other  hand,  is  character- 
ized by  the  entire  absence  of  erections  of  the  penis,  both  overnight 
in  bed,  and  during  the  early  morning  hours;  the  penis  always  re- 


THE  SEXUAL  EPOCH  OF  THE  MENACME.  337 

mains  flaccid,  or  at  most  becomes  semi-erect  only,  insufficiently  rigid 
for  penetration.  Ejaculation  is  much  retarded  or  altogether 
wanting. 

Impotentia  coeundi  in  the  male  may  be  complete,  in  cases  in 
which  the  erection-apparatus  is  entirely  inactive,  and  in  which  even 
an  attempt  at  intercourse  is  out  of  the  question;  or,  and  this  is 
more  frequently  met  with,  it  may  be  partial  only,  and  manifests 
itself  in  various  degrees  of  imperfection  in  the  performance  of 
coitus. 

This  latter  form  may  often  escape  the  woman's  notice.  Whilst 
complete  impotentia  coeundi,  in  which  intromission  of  the  penis  is 
impossible,  is  a  state  about  which  neither  husband  and  wife  can  fail 
to  be  fully  informed,  cases  of  partial  impotence,  with  semi-erection 
of  the  penis  or  premature  ejaculation,  are  often  glozed  over  by  the 
husband,  ignored  by  the  wife,  and  underestimated  by  the  physician — 
and  yet  such  incomplete  intercourse  entails  a  series  of  ill-conse- 
quences alike  upon  the  genital  organs  and  upon  the  nervous  system 
of  the  wife.  Erection  is  incomplete,  and  thus  the  penis  passes  into 
the  vestibule  only,  and  not  deep  into  the  vagina ;  even  if  penetration 
is  more  thorough,  the  venous  return  of  the  blood  from  the  corpora 
cavernosa  is  not  checked  sufficiently  to  distend  the  penis  to  its  full 
size,  and  to  bring  it  into  close  contact  with  the  vaginal  walls ;  or 
ejaculation  occurs  prematurely,  before  the  sexual  organism  of  the 
wife  has  attained  that  supreme  degree  which  is  needful  alike  for 
the  attainment  of  sexual  gratification  and  for  the  occurrence  of 
conception. 

Vaginismus. 

Vaginismus  is  a  disordered  state,  characterized  by  hyperaesthesia 
of  the  hymen  and  of  the  entrance  to  the  vagina,  so  extreme  that, 
even  though  the  organs  may  be  entirely  free  from  any  anatomical 
abnormality,  coitus  is  prevented,  whenever  attempted,  by  violent, 
involuntary  spasmodic  contractions  of  the  constrictor  cunni  and  the 
other  muscles  of  the  urogenital  and  anal  region. 

The  centripetal  paths  of  the  reflex  spasm  characteristic  of 
vaginismus,  run  through  the  branches  of  the  inferior  hypogastric 
plexus,  and  especially  through  the  utero-vaginal  plexus.  The 
spinal  nerves  connected  with  this  part  of  the  sympathetic  are  the 
2d,  3d,  and  4th  sacral.  The  plexuses  are  constituted  by  fibres  in 
part  from  sympathic  and  in  part  from  the  2d,  3d,  and  4th  sacral 
nerves.  Through  the  same  nerves  passes  the  centripetal  motor  tract 

22 


338  THE  SEXUAL  LIFE  OF  WOMAN. 

for  the  transversus  perinei  muscle,  and  for  the  sphincter  and  levator 
ani  muscles.  According  to  Eulenburg,  the  centre  for  this  reflex  is 
to  be  found  at  the  level  of  the  first  sacral  nerve;  when  the  dis- 
turbane  irradiates  more  widely,  the  lumbar  and  sacral  plexuses  as 
a  whole  are  involved.  The  constrictor  cunni  (sphincter  vaginae  or 
bulbo-cavcrnosus  muscle)  is  supplied  by  the  perineal  branch  of  the 
puclic  nerve.  The  symptom-complex  of  vaginismus  consists  of 
violent  spastic  contraction,  for  a  term  varying  greatly  in  duration, 
of  the  constrictor  cunni  (bulbo-cavernosus),  sphincter  ani,  levator 
ani,  and  transversus  perinei  muscles,  the  spasm  spreading,  in  severe 
cases,  to  other  muscles  in  the  neighbourhood,  and  especially  to  the 
adductor  muscles  of  the  thigh;  the  spasm  comes  on  when  any  at- 
tempt at  intercourse  is  made,  and  even  when  the  genitals  are  merely 
touched. 

In  young  married  couples  especially,  vaginismus  is  an  extremely 
distressing  condition,  and  one  that  entails  very  serious  consequences, 
inasmuch  as  the  pains  and  reflex  spasms  which  result  from  any 
attempt  at  coitus,  and  even  from  the  mere  approximation  of  the 
penis  to  the  female  genital  organs,  render  sexual  intercourse  abso- 
lutely impossible.  The  cause  of  this  pathological  manifestation  is 
in  part  to  be  found  in  unskilful  attempts  at  intercourse,  which  have 
stimulated  the  female  genital  organs  at  some  improper  region.  It 
may  be  that  the  young  husband  is  not  fully  instructed  in  sexual 
matters,  and  does  not  really  know  how  coitus  ought  to  be  effected ; 
in  other  cases  there  is  some  abnormality  of  the  hymen,  which  has 
rendered  the  rupture  of  that  membrane  extremely  difficult ;  in  some 
cases  there  is  partial  impotence  in  the  male,  whose  penis  becomes 
semi-erect  only,  so  that  ever  renewed  attempts  at  intercourse  are 
followed  by  ever-renewed  failure.  Any  of  these  causes  may  suffice, 
in  susceptible  women,  to  originate  vaginismus.  The  sufferer  in  these 
cases  will  usually  be  found  on  enquiry  to  be  hereditarily  predisposed 
to  nervous  disorder,  and  to  be  extremely  sensitive  to  pain.  By  the 
fruitless  efforts  of  her  ignorant  or  partially  impotent  husband,  she  is 
sensually  excited  without  ever  being  satisfied ;  the  injured  nervous 
system  responds  by  these  local  spasms,  whilst  ultimately,  in  some  of 
these  cases,  an  actual  psychosis  ensues. 

In  a  certain  number  of  cases,  however,  the  husband  is  in  no  way 
responsible  for  the  origin  of  vaginismus,  which  may  depend  on 
pathological  states  of  the  female  external  genitals,  leading  to 
hyperaesthesia ;  or,  again,  on  primary  hyperaesthesia  of  the  puclic 
nerve  and  its  branches;  or,  finally,  on  general  neurasthenia  and 


THE  SEXUAL  EPOCH  OF  THE  MENACME.  339 

hysteria,  on  excessive  sensibility  and  lack  of  self-control  on  the 
part  of  a  young  girl,  who  has  entered  upon  married  life  under  the 
dominion  of  extravagant  ideas.  Vaginismus  dependent  upon  gen- 
eral neurasthenia  especially  in  cases  in  which  there  is  no  strong 
affection  for  the  husband  to  give  the  spur  to  desire,  and  to  enable 
the  woman  to  bear  with  fortitude  the  pangs  which  form  the  neces- 
sary introduction  to  the  joys  of  wedded  life.  It  must  not  be  for- 
gotten, as  throwing  light  on  the  origin  of  vaginismus,  that  in  the 
digital  vaginal  examination  of  a  virgin  or  even  of  a  young  wife, 
unless  extreme  care  is  taken,  pain  and  painful  muscular  spasms  are 
liable  to  be  evoked. 

The  local  pathological  conditions  of  the  female  genital  organs 
that  are  most  often  met  with  in  cases  of  vaginismus  are :  a  very 
rigid  state  of  the  hymen  ;  inflammation  and  excoriation  of  the  hymen 
and  its  surroundings;  fissures  at  the  vaginal  orifice;  inflammatory 
affections  of  the  vaginal  follicles ;  inflammation  of  the  carunculae 
,  myrtiformes ;  a  peculiar  formation  of  the  vulva,  which  extends 
forwards  over  the  pubic  symphysis,  whereby  the  urethal  orifice 
and  the  hymenal  aperture  come  to  lie  upon  the  pubic  symphysis 
or  the  subpubic  ligament ;  vulvitis ;  herpes  or  eczema  of  the  vulva ; 
kolpitis ;  urethritis ;  fissure  of  the  anus ;  papillary  growths ;  pruritus 
papules ;  urethral  caruncle ;  inflammation  of  Bartholin's  glands ;  at 
times  gonorrhoeal  infection. 

A  case  came  under  my  own  observation  in  which  a  newly  mar- 
ried woman  suffered  from  vaginismus.  The  husband  believed  the 
cause  of  the  trouble  was  his  own  partial  impotence,  consequent 
upon  youthful  venereal  excesses,  and  yielded  to  the  desire  of  his 
wife  and  her  relatives  that  a  divorce  should  be  obtained.  A  year 
later,  the  woman  remarried,  when,  to  her  horror,  the  symptoms  re- 
turned in  full  force.  Now  for  the  first  time  she  consulted  me,  and 
on  local  examination  I  could  detect  no  abnormality  whatever.  The 
vaginismus  was  in  this  instance  a  pure  neurosis,  the  only  possible 
cause  of  which  was  to  be  found  in  bygone  overstimulation  of  the 
vaginal  orifice,  the  wife  admitting  previous  onanistic  excesses.  In 
another  case  known  to  me,  vaginismus  in  the  wife  made  the  hus- 
band an  involuntary  sodomite.  The  movements  of  the  wife  when 
the  spasm  came  on  led  to  the  introduction  of  the  penis  per  anum, 
and  coitus  had  repeatedly  been  effected  by  this  abnormal  route, 
when  the  fact  first  became  apparent  as  the  result  of  a  local 
examination. 

Le  Fort  reports  the  case  of  a  young  Russian  wedded  pair  who 


34O  THE  SEXUAL  LIFE  OF  WOMAN. 

were  spending  their  honeymoon  in  Paris.  The  husband  took  so 
much  to  heart  his  inability  to  fulfil  his  marital  obligations  in  conse- 
quence of  the  vaginismns  from  which  his  wife  suffered,  that  he 
shot  himself  through  the  heart.  The  distressing  situation  of  a 
husband  whose  wife  suffers  from  vaginismus,  rendering  coitus  im- 
possible, is  depicted  in  the  well-known  French  romance,  "Made- 
moiselle Giraitd,  Ma  Femme."  From  a  false  shame,  women  often 
continue  ,to  suffer  from  vaginismus  for  months  and  even  years, 
without  a  single  effective  coitus  having  ever  taken  place ;  it  is  only 
the  consequent  sterility  which  at  last  leads  to  medical  advice  being 
sought.  The  physician  then  usually  ascertains  that  the  hymen  is 
still  intact,  or  at  least  incompletely  destroyed,  that  on  this  mem- 
brane and  on  various  parts  of  the  vulva  there  are  erosions,  and 
that  the  whole  of  the  external  genitals  outside  the  hymen  are  in  a 
state  of  inflammation  more  or  less  acute.  In  other  cases,  however, 
neither  excoriations,  erosions,  nor  inflammation  "can  be  detected,  and 
the  existence  of  vaginismus  can  be  proved  only  by  the  pain  and 
the  muscular  spasm  set  up  by  contact  with  the  vagina.  Often,  in- 
deed, the  cause  of  this  most  distressing  affection  cannot  be  dis- 
covered. 

Introduction  of  the  penis  may  be  rendered  impossible  by  spasm 
of  the  constrictor  cunni  (bulbo-cavernosus)  muscle,  but  equally  so 
by  spasm  of  the  transversus  perinei  or  the  levator  ani  muscle. 
Sometimes  the  spasm  affects  all  three  muscular  groups,  in  which 
case  the  narrowing  of  the  vagina  is  extreme,  and  extends  for  some 
way  up  into  the  canal.  When  the  levator  ani  alone  is  affected  by 
the  spasm,  the  penis  can,  indeed,  be  introduced  into  the  vagina,  to 
encounter  a  powerful  obstacle  in  the  interior  of  that  canal ;  and 
it  may  happen,  when  the  spasm  comes  on  and  affects  the  levator 
ani  only  after  complete  intromission  of  the  penis,  that  the  glans  is 
retained  in  the  vaginal  fornix  by  the  active  contraction  of  the  pelvic 
floor. 

More  or  less  credible  instances  of  penis  captivus  thus  brought 
about  are  on  record.  The  following  history  is  by  Davis:  A  gentle- 
man entering  his  stable  found  therein  his  coachman  and  a  servant- 
maid  in  a  most  compromising  position.  All  endeavours  of  the  pair 
thus  surprised  to  separate  proved  ineffectual,  and  their  attempts  to 
d'raw  apart  caused  them  intense  pain.  Davis  was  sent  for,  and 
ordered  an  iced  douche,  which,  however,  failed  to  liberate  the  im- 
prisoned penis.  Release  was  impossible  until  the  woman  had  been 
placed  under  chloroform.  The  swollen  and  livid  penis  exhibited 


THE  SEXUAL  EPOCH  OF  THE  MENACME.  341 

two  strangulation-furrows,  a  proof  that  two  distinct  areas  of  the 
levator  ani  muscle  had  been  spasmodically  contracted. 

Hildebrand  records  three  cases  observed  by  himself  in  which  there 
was  spasm  of  the  upper  part  only  of  the  vagina,  unaccompanied  by 
vaginismus  (i.  e.,  by  pain).  In  two  of  these  cases,  the  spasm  was 
originated  by  the  contact  of  the  examining  finger  with  very  painful 
ulcers  of  the  portio  vaginalis ;  the  third  patient  had  a  very  sensitive 
prolapsed  ovary.  Fritsch  reports  having  had  on  one  occasion  to 
give  a  woman  chloroform  for  the  release  of  a  swollen  and  im- 
prisoned penis. 

Hildebrand  suggests  that  vaginismus  may  be  caused  by  an  ab- 
normal size  of  the  penis,  or  by  a  condition  occurring  in  weaklings 
and  alcoholic  subjects,  in  whom  the  greatest  swellings  of  the  glans 
penis  occurs  before  intromission,  whilst  this  greatest  swelling  is 
normally  deferred  until  towards  the  end  of  the  act,  when  the  glans 
'is  in  the  vaginal  fornix. 

Schroder  writes  as  follows  regarding  the  etiology  of  vaginismus : 
"  The  affection  is  dependent  upon  trauma,  sustained  in  maladroit, 
frequently  repeated  attempts  at  sexual  intercourse ;  for  this  reason 
it  is  met  with,  in  the  great  majority  of  cases  in  young,  newly  mar- 
ried women.  Impotence  in  the  male  is  by  no  means  necessary  for 
its  production,  and  such  impotence  is  not  even  a  frequent  antecedent. 
Abnormal  narrowness  of  the  vagina,  or  extreme  firmness  of  the 
hymen,  is  occasionally  found,  but  neither  is  in  any  way  necessary; 
all  that  can  be  said  in  this  connection  of  a  small  vaginal  orifice  is, 
that  it  predisposes  to  vaginismus.  If  the  husband  is  devoid  of  pre- 
vious experience  in  sexual  matters,  maladroit  attempts  at  intercourse 
are  exceedingly  likely  to  occur.  The  penis  is  thrust  in  the  wrong 
direction,  pressing  against  either  the  anterior  or  the  posterior  com- 
missure of  the  vulva.  Very  often,  moreover,  the  position  of  the 
vulva,  which  is  subject  to  very  striking  individual  variations,  is 
concerned  in  the  production  of  vaginismus.  There  are  many  women 
in  whom  the  vulva  lies  in  part  in  front  of  the  symphysis  pubis,  so 
that  the  lower  border  of  the  symphysis  lies  below  the  urethral  orifice. 
In  such  cases  the  penis  is  directed  too  far  backwards,  and  instead  of 
passing  into  the  vaginal  orifice,  slips  into  the  fossa  navicu- 
laris.  The  frequent  repetition  of  such  maladroit  attempts  at  inter- 
course gives  rise  to  a  gradually  increasing  sensitiveness  of  the 
parts  concerned,  with  the  formation  of  excoriations.  It  now  results 
that,  on  the  one  hand,  the  woman  dreads  attempts  at  intercourse 
on  account  of  the  pain  to  which  they  give  rise;  she  shrinks  away 


342  THE  SEXUAL  LIFE  OF  WOMAN. 

from  the  man,  so  that  penetration  of  the  vagina  by  the  penis  is 
rendered  even  more  difficult  than  it  was  before;  and,  on  the  other 
hand,  ungratified  sexual  desire  leads  to  the  frequent  repetition  of 
attempts  at  complete  intercourse  (from  which,  moreover,  if  con- 
ception should  ensue,  a  cure  of  the  trouble  is  expected).  In  this  way, 
the  trauma  is  rendered  more  severe,  the  congestion  and  excoriation 
of  the  fossa  navicularis  or  of  the  urethral  region  are  aggravated, 
and  the  sensitiveness  of  the  parts  increases  to  such  a  degree  that  the 
woman  thus  affected  screams  out  when  the  vulva  is  merely  touched. 
Ultimately  reflex  cramps  set  in  whenever  intercourse  is  attempted, 
and  we  then  have  the  fully  developed  clinical  picture  of  va- 
ginismus." 

Winckel  maintains  that  in  most  cases  there  are  two  principal 
elements  in  the  causation  of  vaginismus.  In  the  first  place,  in  con- 
sequence of  more  or  less  pronounced  anatomical  changes,  there  is 
undue  sensitiveness  and  tenderness  of  the  vaginal  inlet  and  its 
neighbourhood,  and  in  exceptional  cases  also  of  the  upper  part  of 
the  vagina,  the  uterus,  and  the  ovaries.  In  the  second  place,  the 
patient  manifests  an  increased  general  sensitiveness  and  nervous 
irritability ;  this  is  in  some  cases  primary,  but  in  others  it  is  entirely 
the  result  of  the  repeated  stimulation;  and  in  either  case  it  is 
heightened  by  the  effects  of  ungratified  sexual  desire. 

A.  Mcfrtin  points  out  that  the  spasm  of  the  muscles  of  the  pelvic 
floor,  and  especially  of  the  levator  ani  muscle,  upon  which  vaginis- 
mus depends,  may  be  due  in  some  cases  to  the  influence  of  chill, 
since  the  same  cause  will  lead  to  pathological  contractions  in  other 
muscular  areas.  But  in  such  cases  it  is  always  open  to  question  if 
masturbation  or  some  other  sexual  perversion  is  not  the  true  cause 
of  the  disorder.  In  some  instances  vaginismus  is  merely  a  symp- 
tom, in  extremely  sensitive  women,  of  various  diseases  of  the  re- 
productive organs,  and  is  brought  on  by  the  increased  pain  which 
in  such  cases  is  caused  by  attempts  at  intercourse ;  when  produced 
in  this  way,  vaginismus  is  usually  a  transient  manifestation. 

Veil  considers  that  among  the  pathological  conditions  giving  rise 
to  vaginismus,  we  must  also  enumerate  diseases  of  the  internal 
pelvic  organs,  such  as  chronic  metritis,  displacements  of  the  uterus, 
oophoritis,  etc. ;  but  he  also  attaches  great  importance  to  nervous 
predisposition,  consequent  upon  previous  sexual  stimulation,  and 
upon  pre-existing  inflammatory  changes  due  to  gonorrhoeal  infec- 
tion. A  peculiar  form  of  vaginismus  is,  according  to  Veit,  some- 
times observed  after  the  birth  of  the  first  child ;  happily  the  dura- 
tion of  this  is  usually  brief.  After  parturition  the  vulval  mucous 


THE  SEXUAL  EPOCH  OF  THE  MENACME.  343 

membrane  remains  for  a  time  very  tender,  and  when  cohabitation 
is  resumed,  often  too  soon,  and  perhaps,  after  the  enforced  absti- 
nence, too  frequently  repeated  at  brief  intervals,  fissures  are  readily 
produced.  Moreover,  vaginismus  which  has  existed  prior  to  par- 
turition may,  in  some  cases,  recur  after  that  event.  An  unusual 
position  of  the  vulva,  undue  smallness  of  the  vaginal  inlet,  and 
relative  impotence  of  the  man,  may  combine  to  cause  such  a  recur- 
rence. Finally,  vaginismus  often  persists  throughout  pregnancy, 
and  manifests  itself  during  parturition.  The  magical  effect  which 
chloroform  has  in  some  primiparae,  when  the  head  is  delayed  at 
the  vulva,  is  explicable  only  by  the  supposition  of  vaginismus. 

According  to  Arndt,  vaginismus  is  not  purely  a  local  disorder, 
but  is  in  many  cases  the  local  manifestation  of  a  neuropathic  diath- 
esis, which  may  in  some  instances  lead  to  general  mental  disorder. 

Olshausen  regards  hypersesthesia  and  vaginismus  as  different 
stages  of  a  single  disease ;  he  believes  that  the  excessive  sensitiveness 
is  seated  chiefly  in  the  hymen ;  he  explains  the  spasm  as  the  reflex 
result  of  fissures  and  inflammatory  changes.  Pozzi  considers  that 
excessive  nervous  irritability  and  an  irritable  state  of  the  vulva 
are  the  indispensable  preliminaries  to  the. occurrence  of  vaginismus. 
Herman  distinguishes  between  excessive  smallness  of  the  vaginal 
inlet  and  vaginismus;  he  regards  the  latter  as  a  nervous  disorder, 
characterized  by  hyperaesthesia  of  the  vulva,  and  by  spasmodic 
contraction  of  the  levator  ani  and  adjoining  muscles.  Frost  dis- 
tinguishes vaginodynia  from  vaginismus ;  in  vaginodynia  the  pain 
is  so  intense  as  to  cause  syncope,  and  the  muscular  spasm  involves 
the  entire  length  of  the  vagina. 

It  is  a  notable  fact,  to  which  Veit  has  especially  drawn  attention, 
that  among  the  poorer  classes  of  the  population,  vaginismus  is 
practically  unknown.  Among  women  of  these  classes,  their  sex- 
sual  needs,  not  having  been  so  much  lessened  by  "  culture,"  suffice 
to  withdraw  their  attention  even  from  the  pains  of  defloration, 
which  would  otherwise  often  be  very  severe ;  whereas  the  sexually 
neurasthenic  woman  of  the  upper  classes,  filled  with  dread  at  the 
idea  of  the  pain  she  expects  to  suffer,  and  not  infrequently  in  a 
condition  of  hyperexcitability  or  hypersensibility  dependent  upon 
previously  employed  abnormal  means  of  sexual  gratification,  is 
unable  to  endure  the  pains  of  defloration  even  when  these  might  be 
expected  to  prove  far  from  severe. 

In  some  cases,  painful  contractions  of  the  vagina,  to  which  we 
cannot  properly  give  the  name  of  vaginismus,  arise  from  organic 
diseases  of  the  uterus  and  the  uterine  annexa;  these  painful  con- 


344  THE  SEXUAL  LIFE  OF  WOMAN. 

tractions  render  copulation  impossible.  Von  Hofmann  reports  the 
case  of  a  young  prostitute,  who  found  herself  unable  to  continue 
the  practice  of  her  profession  owing  to  the  severe  pain  she  suffered 
during  intercourse ;  she  died,  and  the  post  mortem  examination  dis- 
closed bilateral  salpingitis,  with  reproductive  organs  in  other 
respects  normal. 

Maladroit  and  incomplete  attempts  at  intercourse,  and  the  con- 
sequent repeated  failure  to  obtain  complete  sexual  gratification, 
affect  a  woman's  nervous  system  to  a  varying  degree;  but  apart 
from  this,  in  women  who  have  long  cohabited  with  men  of  deficient 
sexual  potency,  we  often  find  a  remarkable  condition  of  complete 
relaxation  of  the  genital  organs,  associated  with  great  hyper  secre- 
tion of  the  mucous  membrane,  flaccidity  of  the  muscles  of  the 
pelvic  floor,  and  displacements  of  the  uterus.  Moreover,  the  ner- 
vous shock  to  which  the  repeated  but  unsatisfying  attempts  at  inter- 
course give  rise,  affects  the  spinal  cord  in  such  a  manner  that 
symptoms  of  spinal  irritation  ensue.  The  patient  complains  of 
pains  in  the  back,  the  loins,  and  the  nape  of  the  neck;  these  pains 
also  radiate  round  the  front  of  the  abdomen  and  along  the  inter- 
costal spaces ;  hyperaesthetic  points  may  be  detected  when  the  finger 
is  passed  along  the  spine;  there  is  weakness  of  the  limbs  with  a 
sensation  of  numbness;  and  neuralgic  manifestations  of  varying- 
nature  occur. 

The  dangers  which  sexual  intercourse  may  entail  upon  women 
—  over  and  above  the  irritable  conditions  and  inflammatory  dis- 
orders of  the  female  reproductive  organs,  dependent  upon  impetu- 
ous or  unduly  frequent  coitus,  or  upon  coitus  practised  during 
menstruation  —  are  principally  due  to  gonorrhoeal  and  syphilitic 
infection  transmitted  by  the  cohabitating  male. 

Cardiac  Troubles  Due  to  Sexual  Intercourse. 

Among  the  troubles  from  which  women  at  times  suffer  as  a  re- 
sult of  sexual  intercourse,  certain  cardiac  disorders  are  especially 
worthy  of  attention. 

Every  act  of  sexual  intercourse  in  a  young  and  sensitive  woman 
exercises  an  exciting  influence  on  the  nervous  mechanism  con- 
trolling the  cardiac  movements,  and  this  influence  is  more  clearly 
manifested  in  a  degree  directly  proportional  to  the  intensity  of 
the  sexual  orgasm.  The  heart's  action  is  markedly  increased  in 
frequency,  the  cardiac  impulse  is  more  powerful,  the  large  arteries 
of  the  neck  are  seen  to  pulsate  far  more  vigorously,  the  conjunctiva 


THE  SEXUAL  EPOCH  OF  THE  MENACME.  345 

is  markedly  injected,  the  respiration  is  increased  in  frequency,  the 
respiratory  movements  are  more  superficial  and  have  a  panting 
character. 

But  when,  in  a  woman  who  is  sexually  irritable  in  an  excessive 
degree,  the  peripheral  stimulation  occurring  in  the  act  of  sexual 
intercourse  is  unusually  powerful,  there  may  result  a  notable  in- 
crease or  modification  of  the  reflex  manifestations  which  normally 
occur  during  sexual  intercourse  in  the  province  of  cardiac  activity ; 
similar  results  ensue  when  there  is  a  summation  of  stimuli  owing 
to  excessive  sexual  intercourse,  or  contrariwise  when  the  act  of 
intercourse  is  broken  off  just  before  its  physiological  climax  and 
the  natural  termination  of  the  orgasm  fails  to  occur. 

The  former  cause  is  not  infrequent  in  young  wives"  during  the 
period  of  the  honeymoon.  The  latter  cause  is  in  operation  when 
there  are  diseases  of  the  female  reproductive  organs  preventing  the 
physiological  completion  of  intercourse ;  but  especially  in  conse- 
quence of  the  modern  practice  of  coitus  interruptus,  in  which  the 
man  breaks  off  the  act  of  intercourse  the  moment  he  feels  that 
ejaculation  is  imminent,  without  troubling  himself  regarding  the 
natural  course  of  sexual  excitement  in  the  woman.  Yet  another 
cause  of  excessive  cardiac  reflex  manifestations  in  women  is  in- 
complete potency  of  the  male,  which  may  either  cause  a  premature 
ejaculation  of  semen,  or  may  lead  to  incomplete  penetration  of  the 
penis. 

In  all  such  cases,  as  a  result  of  sexual  intercourse,  there  may 
arise  cardiac  disorders  of  various,  kinds ;  among  these,  tachycardial 
paroxysms  are  the  most  frequent,  occurring  either  inter  actum, 
or  at  a  longer  or  shorter  interval  after  intercourse. 

In  several  cases  of  vaginismus  occurring  in  young  married  women 
which  have  come  under  my  notice,  it  was  observed  that  the  at- 
tempts at  intercourse  gave  rise  to  violent  involuntary  spasmodic 
contractions  of  the  constrictor  cunni  and  the  other  muscles  of  the 
urogenital  and  anal  regions,  and  in  addition  it  was  found  that 
these  attempts  were  followed  by  tachycardial  paroxysms  with 
dyspnceic  manifestations,  lasting  for  a  considerable  period,  it  might 
be  as  long  as  one  or  two  hours. 

In  women  who  had  practised  coitus  reservatus  for  a  prolonged 
period,  in  fact  for  several  years,  in  such  a  manner  that,  notwith- 
standing the  occurrence  of  intense  voluptuous  excitement,  complete 
sexual  gratification  rarely,  if  ever,  occurred  —  in  such  women,  in 
whom  these  marital  malpractices  seemed  to  have  profoundly  influ- 


THE  SEXUAL  LIFE  OF  WOMAN. 

enced  their  psychical  life,  I  have  frequently  witnessed  a  form  of 
reflex  cardiac  disorder  which  I  must  regard  as  a  variety  of  the 
multiform  neurasthenia  cordis  vasomotoria.  In  such  women,  still 
at  the  climax  of  their  physical  powers  and  of  their  sexual  needs, 
attacks  of  palpitation  suddenly  occur  at  irregular  intervals,  several 
times  daily  or  less  frequently.  Associated  with  this  increased  fre- 
quency of  the  cardiac  activity  are  an  extremely  distressing  feeling 
of  anxiety,  a  sensation  of  faintness,  headache,  vertigo,  a  weakness 
of  the  muscular  system,  and  at  times  actual  attacks  of  syncope. 
Physically,  the  women  are  extremely  depressed,  irritable,  inclined 
to  weep,  unhappy,  and  weary  of  life.  At  the  same  time,  digestion 
is  impaired,  the  appetite  is  small,  and  there  is  constipation.  The 
pulse  is  in  most  cases  feeble,  small,  of  low  tension,  easily  com- 
pressible, increased  in  frequency,  often  intermittent,  sometimes 
more  distinctly  arhythmical.  The  heart  is  found  to  be  sound  on 
physical  examination,  nor  can  any  abnormality  be  detected  in  the 
great  vessels.  The  lower  extremities  are  free  from  cedema;  the 
urine  does  not  contain  albumen. 

Women  thus  affected  are  sometimes  believed  to  be  suffering 
from  cardiac  disorder,  in  other  cases  they  are  subjected  to  various 
modes  of  gynecological  treatment;  until  at  length  the  physician,  by 
appropriate  questions,  becomes  enlightened  regarding  the  true 
cause"  of  the  cardiac  disorder,  namely,  coitus  interruptus.  If  it  is 
possible  to  prohibit  effectually  this  unwholesome  practice,  the  car- 
diac symptoms  soon  cease  to  recur. 

Finally,  in  women  at  the  climacteric  age,  cardiac  troubles  some- 
times ensue,  which  are  dependent  on  interference  with  sexual  inter- 
course in  consequence  of  anatomical  changes  in  the  vagina ;  changes 
of  this  character  frequently  occur  at  the  time  of  the  menopause; 
owing  to  hyperaemic  or  inflammatory  processes,  a  partial  or  general 
stricture  of  the  vaginal  passage  results ;  in  many  cases  this  passage 
becomes  narrower,  shorter,  and  almost  conical  in  shape,  whilst  the 
vaginal  inlet  is  greatly  diminished  in  size.  Such  a  vaginal  stric- 
ture, which  Hegar  has  also  seen  in  younger  women  after  an  arti- 
ficial climacteric  (oophorectomy),  interferes  with  sexual  inter- 
course ;  and  the  incomplete  sexual  gratification  gives  rise  to  a  series 
of  nervous  manifestations,  and,  among  others,  to  the  above  de- 
scribed reflex  cardiac  neurosis. 

Whether,  and  in  which  cases,  the  cardiac  disorders  evoked  as  a 
result  of  the  local  stimulatory  influences  of  sexual  intercourse,  are 
dependent  'on  a  reflex  stimulation  of  the  sympathetic  nerve  on  the 


THE  SEXUAL  EPOCH  OF  THE  MENACME.  347 

one  hand,  or  upon  a  transient  paresis  of  the  inhibitory  centre  of 
the  heart  and  of  the  vasomotor  centre  on  the  other,  cannot  here 
be  fully  discussed;  just  as  little  can  we  consider  in  what  manner 
the  psyche  is  sympathetically  affected  by  the  irritative  processes  in 
the  genital  organs,  and  its  functional  activity  thus  impaired. 

Here  I  can  do  no  more  than  briefly  state  that  experience  has 
taught  me  that  sexual  intercourse  is  competent  to  originate  cardiac 
troubles  in  women. 

1.  In  extremely  sensitive,  sexually  very  irritable  women,  tachy- 
cardial  paroxysms  may  result  from  sexual  excesses. 

2.  Tachycardial  paroxysms  with  dyspnoea  occur  in  young  women 
affected  with  vaginismus ;  also  in  women  at  the  climacteric  with 
constrictive  changes  in  the  vagina. 

3.  Cardiac  troubles,  characterized  mainly  by  symptoms  indicating" 
diminished  vascular  tone,  occur  in  women  who  have  long  prac- 
tised coitus  interruptus  with  incomplete"  gratification  of  their  volup- 
tuous desires. 

Dyspareunia. 

In  normal  conditions  the  act  of  sexual  intercourse  is  accom- 
panied in  women,  as  in  men,  by  a  voluptuous  sensation,  and  this 
sensation  must  be  regarded  as  a  necessary  link  in  the  chain  of  those 
•processes  by  which  gratification  of  the  sexual  impulse  —  the  most 
powerful  of  all  our  natural  impulses  —  is  obtained.  The  absence 
of  this  voluptuous  sensation  in  a  woman,  the  state  in  which  she 
experiences  during  coitus  no  voluptuous  sensations,  but  feels  either 
apathy,  or  positive  distaste,  is  termed  dyspareunia :  in  former  times 
it  was  also  known  as  anaphrodisia.  This  abnormal  state  of  sexual 
sensibility,  which  up  to  the  present  is  hardly  alluded  to  in  gyneco- 
logical textbooks,  has  received  remarkably  little  attention  from 
the  medical  standpoint,  and  its  importance  has  been  underesti- 
mated. Most  unfortunately  so,  for  dyspareunia  is  an  important 
symptom,  exercising  a  powerful  influence  on  the  general  health  of 
the  woman  who  suffers  from  it,  upon  her  social  status  in  marriage, 
and,  as  is  easy  to  understand,  upon  her  procreative  capacity. 

Dyspareunia  must  be  clearly  distinguished  from  two  somewhat 
similar  conditions,  with  which  at  first  sight  it  is  liable  to  be  con- 
fused, namely,  from  anaesthesia  sexualis,  and  from  vaginismus.  By 
sexual  anaesthesia  we  understand,  as  previously  explained,  the  absence 
of  the  sexual  impulse,  a  symptom  which,  when  the  reproductive  or- 
gans are  normal  in  structure  and  function,  is  either  of  central  nervous 
origin,  a  result  of  disease  of  the  brain  or  spinal  cord,  or  else  is 
due  to  general  nutritive  disorders  such  as  diabetes,  morphinism, 


348  THE  SEXUAL  LIFE  OF  WOMAN. 

or  alcoholism.  A  woman  affected  with  dyspareunia  does,  however, 
experience  the  sexual  impulse,  it  may  be  very  actively,  but  sexual 
intercourse  brings  about  no  gratification  of  her  desires.  In 
vaginismus,  on  the  other  hand,  the  introduction  of  a  foreign  body, 
that  is  to  say  of  the  membrum  virile,  into  the  vagina,  gives  rise  to 
painful  reflex  cramps  of  the  sphincter  vaginae,  or  of  the  muscles 
of  the  pelvic  floor,  whereby  the  completion  of  coitus  is  rendered 
impossible :  whereas  in  dyspareunia  coitus  can  be  effected,  but  gives 
rise  to  no  voluptuous  sensations. 

The  pleasure  which  normally  occurs  in  woman  during  sexual  in- 
tercourse is  brought  about  in  this  way,  that  contact  with  and  fric- 
tion by  the  penis  stimulates  the  sensory  nerves  of  the  clitoris,  the 
vulva,  the  vestibule,  and  the  vagina;  this  stimulus  is  propagated  to 
the  cerebral  cortex,  where  it  gives  rise  to  voluptuous  sensations,  and 
then,  by  reflex  stimulation  of  the  genito-spinal  centre,  gives  rise  to 
a  series  of  reflex  discharges.  The  pudic  nerve,  a  branch  of  the 
sacral  plexus,  supplies  the  female  external  genital  organs.  Some 
of  its  branches  pass  in  the  clitoris  to  a  peculiar  form  of  nervous 
end-organ  discovered  by  VV.  Krause,  Krause's  genital  corpuscles: 
the  structure  of  these  corpuscles  appears  to  fit  them  exceptionally 
well  for  the  transmission  of  stimulatory  waves  to  the  nerve  centres. 
"  When  this  stimulus,"  says  Hcnsen,  in  his  work  on  the  physiology 
of  reproduction,  "  in  addition  to  other  effects,  also  gives  rise  to  a 
voluptuous  sensation,  the  cause  must  be  sought  in  central  nervous 
connections  and  apparatus.  Similar  relations  are  to  be  found  in 
connection  with  the  mechanism  of  nutrition,  for  example,  in  the 
association  of  hunger,  appetite,  agreeable  sensations  of  taste,  the 
act  of  mastication,  and  the  secretion  of  saliva."  By  means  of  this 
stimulus,  several  reflex  processes  are  originated  in  the  reproductive 
canal,  the  most  notable  of  which  are  the  erection  of  the  clitoris, 
and  the  ejaculation  of  the  secretions  of  various  glands.  The  cav- 
ernous tissue  of  the  clitoris  is  connected  with  that  of  the  bulbus 
vestibuli,  and  the  dorsal  nerve  of  the  clitoris  is  one  of  the  principal 
nerves  of  voluptuous  sensation.  The  venous  plexus  constituting 
the  bulb  of  the  vestibule  lies  at  either  side  along  the  margin  of  the 
vestibule  at  the  boundary  between  the  labium  ma  jus  and  the  labium 
minus,  and  laterally  it  is  covered  by  the  constrictor  cunni*  muscle. 

*  Constrictor  Cunni  Muscle. —  In  women  the  bulbocavernosus  muscles, 
right  and  left,  form,  as  it  were,  a  sphincter  to  the  vaginal  outlet.  Hence  the 
alternative  names  of  sphincter  vaginae  and  constrictor  cunni  muscle.  The 
latter  name  is  in  common  use  in  Germany,  but,  though  appropriate,  is  rarely 
employed  in  England. — TRANSL. 


THE  SEXUAL  EPOCH  OF  THE  MEN  ACME.  349 

During  coitus  the  blood  is  driven  out  of  this  bulb  into  the  glans 
clitoridis,  and  thus  the  sensibility  and  the  erection  of  the  glans  are 
increased.  The  constrictor  cunni  and  ischiocavernosus  muscles 
draw  the  clitoris,  which  is  bent  at  a  right  angle  downwards,  into 
contact  with  the  penis.  By  means  of  the  pressure  of  the  con- 
strictor cunni,  the  mucous  secretion  of  Bartholin's  glands,  which 
open  into  the  vulva  at  the  back  of  the  labia  majora,  is  expressed. 

As  additional  reflex  actions,  dependent  upon  the  activity  of  the 
reflex  centre  in  the  lumbar  enlargement  of  the  spinal  cord,  there 
ensue  contractions  of  the  vagina,  peristaltic  movement  of  the  tubes, 
some  descent  of  the  uterus,  relaxation  of  the  os  uteri  and  rounding 
of  this  orifice,  and  induration  of  the  poitio  vaginalis,  whereby  the 
tubal  and  uterine  mucus  and  the  secretion  of  the  cervical  glands 
are  expressed.  This  process  of  ejaculation  constitutes  the  culmi- 
nating point  of  the  voluptuous  sensation  occurring  in  the  sexual 
act;  this  act  thus  exhibits  two  phases,  the  sensation  of  friction,  and 
the  sensation  of  ejaculation. 

With  regard  to  voluptuous  sensations,  and  processes  analagous 
to  pollutions,  occurring  in  women,  we  append  an  extract  from 
von  Krafft-Ebing. 

"The  occurrence  of  voluptuous  excitment  during  coitus  is  de- 
pendent in  the  women,  just  as  in  the  man,  upon: 

"  i.  The  peripheral  influence  of  the  intensity  and  duration  of  the 
sensory  stimulation  (anaesthesia  of  the  genital  passage  may  be  the 
cause  of  the  absence  of  voluptuous  sensation).  2.  The  condition 
of  excitability  of  the  reflex  (ejaculation)  centre  in  the  lumbar 
spinal  cord.  The  activity  of  this  centre  varies  within  wide  limits, 
not  merely  in  different  individuals,  but  in  the  same  individual  at 
different  times.  There  are,  indeed,  women  in  whom  it  seems  as 
if  this  centre  were  always  in  vigorous  activity.  In  normal  women, 
the  irritability  of  the  centre  appears  to  be  most  marked  at  the 
menstrual  epoch,  and  to  decline  rapidly  soon  after  menstruation. 
In  pathological  conditions,  the  activity  of  the  centre  may  be  tem- 
porarily in  abeyance  (organic  inhibitory  processes,  such  as  are  seen 
in  certain  cases  of  hysteria  with  temporary  frigidity)  ;  or  again 
the  centre  may  be  abnormally  active  owing  to  irritable  weakness 
(neurasthenia  sexualis),  in  consequence  of  which  ejaculation  may, 
just  as  in  the  male  in  similar  circumstances,  occur  too  easily.  3. 
The  occurrence  of  the  voluptuous  sensation  in  woman  is  unfavour- 
ably influenced  by  psychical  inhibitory  perceptions  (analogous  to  the 
inhibitory  influence  of  psychical  processes  in  the  male,  such  as,  for 
example,  fear  of  incapacity  to  perform  sexual  intercourse).  As 


3$o  THE  SEXUAL  LIFE  OF  WoMAtf. 

examples  of  such  inhibitory  perceptions  in  women  may  be  men- 
tioned, dislike  of  the  man,  physical  loathing  to  sexual  inter- 
course, etc." 

Gutceit  records  interesting  experiences,  which  are  readily  intelli- 
gible in  view  of  what  we  have  already  quoted.  He  finds  that  of 
ten  women  after  defloration,  two  only  immediately  experience  full 
sexual  pleasure.  Of  the  eight  others,  four  only  have  an  agreeable 
sensation  produced  by  the  friction  during  coitus:  but  the  sensation 
of  ejaculation  does  not  make  its  appearance  until  the  lapse  of  at 
least  six  months,  or  it  may  be  even  several  years,  after  marriage. 
In  the  remaining  four  women,  pleasure  during  sexual  intercourse 
may  never  become  properly  established.  The  women  of  the  first 
class  are  described  by  the  author  as  being  of  a  very  ardent  tem- 
perament, and  passionately  attached  to  their  husbands.  In  such 
women,  the  sensation  of  ejaculation  occurs  during  intercourse  with 
any  man  toward  whom  they  are  sympathetic.  Women  of  the  second 
class  are  of  a  less  ardent  temperament,  and  are  often  comparatively 
indifferent  toward  the  man  with  whom  they  cohabit.  Women  of 
the  third  class  have  little  or  no  amatory  feeling,  and  they  either 
hate  the  man  with  whom  they  are  cohabiting,  or  at  least  feel 
physical  repulsion  to  the  idea  of  intercourse  with  him.  Gutceit 
considers  that  meretrices  usually  belong  to  the  third  category.  In 
the  practice  of  their  trade,  they  make  a  counterfeit  of  voluptuous 
enjoyment,  and  only  experience  real  sexual  gratification  in  inter- 
course with  the  man  of  their  choice. 

It  is  of  great  practical  interest,  alike  from  the  gynecological  and 
from  the  neuropathological  standpoint,  to  determine  the  conse- 
quences in  women  of  ungratifying  sexual  intercourse.  In  the  pres- 
ent state  of  our  experience  it  must  be  assumed  that  the  effect  of 
abnormal  sexual  intercourse,  that  is  of  intercourse  which  does  not 
culminate  in  gratification  produced  by  the  sensation  of  ejaculation, 
is  deleterious.  This  is  explained  by  the  fact  that,  owing  to  the 
absence  of  the  muscular  contraction  of  the  genital  passage,  the 
latter  remains  engorged  with  blood ;  the  resultant  hypersemia  passes 
away  very  slowly,  and,  when  frequently  repeated,  gives  rise  to 
chronic  tissue  changes,  manifesting  themselves  as  diseases  of  the 
reproductive  organs.  Injury  to  the  nervous  system  ensues,  partly 
in  consequence  of  these  organic  changes,  partly  also  in  consequence 
of  psychical  non-gratification  in  the  widest  sense  of  the  term.  The 
nervous  disorders  thus  produced  are  typical  forms  of  (sexual) 
neurasthenia ;  and  in  cases  in  which  the  pathogenesis  is  predomi- 
nantly psychical  (antipathy  to  the  husband,  etc.)  hysterical  types 


THE  SEXUAL  EPOCH  OF  THE  MENACME.  351 

of  disorder  are  especially  frequent.  Von  Krafft-Ebing  believes  that 
incomplete  coitus,  that  is,  coitus  not  culminating  in  the  sensation 
of  ejaculation,  is  a  frequent  cause  of  hysterical  disorders  in  womeji. 

When  once  the  clinical  picture  of  neurasthenia  sexualis  is  fully 
developed,  each  act  of  intercourse  (like  pollutions  or  coitus  in  the 
sexually  neurasthenic  male)  gives  rise  to  renewed  troubles,  which 
are  easily  recognized  as  symptoms  of  venous  stasis  in  the  repro- 
ductive organs  (sacrache,  sensations  of  weight  and  bearing-down 
in  the  pelvis,  fluor  albus)  :  in  addition  we  observe  exacerbations 
of  the  lumbar  spinal  disorder,  in  the  form  of  spinal  irritation, 
irradiating  pains  in  the  sacral  plexus,  etc.  In  this  way  general 
neurasthenia  develops.  The  conditions  found  in  such  cases  on 
gynecological  examination  (chronic  endometritis,  metritis,  oopho- 
ritis,  etc.)  are  produced  by  the  same  cause  as  the  nervous  symp- 
toms, namely,  by  an  unhygienic  mode  of  sexual  intercourse.  They 
are  not  the  cause  of  the  neurosis,  but  important  concomitant  dis- 
orders ;  and  their  effect  in  rendering  the  nervous  disturbances  more 
severe  must  be  freely  admitted. 

Among  important  causes  of  ungratifying  coitus  must  be  enumer- 
ated: weak  erection  and  ejaculatio  praecox  in  the  male,  rendering 
the  stimulation  inefficient;  in  addition,  coitus  reservatus,  coitus  in- 
terruptus,  and  coitus  condomatus.  If  the  noxious  influence  is  fre- 
quently repeated,  the  occurrence  of  neurasthenia  sexualis  and  its 
consequences  is  greatly  to  be  feared,  and  in  women  of  neuropathic 
constitution  it  is  practically  inevitable. 

Unsympathetic  coitus  appears  to  act,  not  merely  in  a  somatic 
manner,  but  mainly  upon  the  psyche,  and  to  originate  states  of 
hystero-neurasthenia  or  pure  hysteria.  If  the  influence  of  such  un- 
hygienic conditions  of  the  vita  sexualis  co-operates  with  that  of 
inherited  or  acquired  sensuality,,  further  dangers  ensue:  in  cases 
of  ungratifying  sexual  intercourse,  the  danger  of  manustupration ; 
in  cases  of  unsympathetic  intercourse,  the  danger  of  psychical  onan- 
ism,  or  that  of  marital  infidelity. 

Although  until  recently  the  matter  received  but  little  attention, 
it  must  now  be  regarded  as  a  well-established  fact,  that  in  the 
female  (as  in  the  male)  the  climax  of  voluptuous  sensation  in  sexual 
intercourse  is  normally  characterized  by  a  process  of  ejaculation, 
accompanied  by  a  voluptuous  sensation  of  ejaculation,  dependent 
upon  the  acme  of  excitement  of  a  reflex  centre  in  the  lumbar  en- 
largement of  the  spinal  cord. 

Just  as  in  the  male,  this  centre  may  be  excited  to  action,  not  only 
by  local  stimulation  of  the  genital  organs,  but  also  by  (psychical) 


ni  I  I- K  I-    or   OSYl£Ol-A 


352  THE  SEXUAL  LIFE  OF  WOMAN. 

stimuli  proceeding  from  the  brain  (pollutions),  so  also  in  the 
female  a  similar  process  may  occur,  and  for  this  reason  it  is  cor- 
rect to  speak  of  "  pollutions  in  the  female."  Rosenthal  appears  to 
have  been  the  first  writer  to  speak  of  pollutions  in  women.  In  his 
clinical  study  of  nervous  diseases,  Rosenthal  described  processes  of 
the  nature  of  pollutions,  originated  in  erotically  over-stimulated 
women  by  lascivious  dreams.  In  one  case  he  detected  the  outflow 
of  a  "  mucus-like  "  fluid  from  the  apparently  intact  genital  organs ; 
he  believed  this  to  proceed  from  the  ducts  of  Bartholin's  glands, 
and  from  the  mucous  glands  surrounding  the  urethral  orifice.  Fere 
reports  the  case  of  a  patient  who  had  an  erogenic  zone  in  the  region 
of  the  upper  part  of  the  sternum;  pressure  on  this  zone  gave  rise 
to  a  profuse  secretion  of  vulvo-vaginal  fluid.  In  this  connection 
we  may  .also  recall  the  "  clitoris-crises  "  to  which  tabetic  women 
are  subject.  Gutceit  described  the  process  of  pollution  in  women 
in  the  following  words :  "  It  is  remarkable  that  in  dreams 
such  women  experience  the  sensation  of  ejaculation." 

The  psychical  preliminary  is  invariably  constituted  by  lascivious 
dream  perceptions.  It  merely  remains  open  to  question  whether 
this  process,  which  in  the  male  is  indisputably  physiological,  in  the 
female  may  be  said  to  occur  within  physiological  limits.  The  re- 
searches published  by  von  Krafft-Ebing.  more  than  twenty  years 
ago,  under  the  title  "  Concerning  Processes  Analogous  to  Pollu- 
tions Occurring  in  the  Female,"  gave  negative  results  as  far  as 
healthy  individuals  were  concerned;  on  the  other  hand,  the  phe- 
nomenon in  question  was  by  no  means  rare  in  nervously  disordered, 
and  above  all  in  sexually  asthenic  women.  The  neurosis  was  in 
part  found  as  a  result  of  psychical  or  manual  onanism  in  virgins 
with  morbidly  intensified  libido :  in  part  in  married  women,  as  a 
result  of  ungratifying  coitus,  as  previously  described:  in  part,  also, 
in  married  women  with  powerful  libido  and  enforced  abstinence 
from  intercourse,  owing  to  acquired  impotence  or  death  of  the 
husband. 

Just  as  in  the  case  of  .the  neurasthenic  male,  these  pollutions 
made  the  primary  neurosis  more  severe,  and  relief  from  the  nervous 
trouble  was  not  obtained  until  the  factor  of  the  "  pollutions  "  had 
been  recognized,  and  made  the  object  of  special  treatment.  In  ex- 
ceptional cases  the  "  pollutions  "  appeared  to  be  the  starting  point 
of  the  entire  neurosis. 

It  was  further  remarkable,  again  here  displaying  analogy  with 
what  occurs  in  the  male,  how  much  stronger  and  more  deleterious 


fi£U 
iD   3f 


THE  SEXUAL  EPOCH  OF  THE  MENACME.  353 

was  the  shock-effect  of  an  inadequate  process  of  ejaculation  occur- 
ring in  a  sexual  dream,  as  compared  with  the  far  less  deleterious 
influence  of  similar  incomplete  ejaculation  when  occurring  via 
coitus.  In  very  severe  degrees  of  neurasthenia  sexualis,  just  as 
in  the  male,  the  waking  imagination  may  give  rise  to  a  "  pollution." 
In  such  cases  the  shock-effect  on  the  nerve  centres  tends  to  be 
excessively  severe.  A  still  higher  degree  of  irritability  of  the  genital 
system  appears  to  exist  in  cases  in  which  excitement  and  orgasm  of 
the  reproductive  organs  may  culminate  in  a  "  pollution  "  by  purely 
spinal  paths,  without  the  intervention  of  the  imagination.  The  sig- 
nificance of  this  fact  would  appear  to  be  considerable  for  the  proper 
comprehension  and  for  the  treatment  of  certain  conditions  of  neu- 
rasthenia (sexualis)  in  the  female.  The  "pollution"  may  here 
be  the  actual  cause  of  the  neurosis.  But  in  any  case,  in  the  female, 
the  occurrence  of  pollutions  is  an  extremely  important  symptom 
as  regards  both  diagnosis  and  therapeutics.  It  is  extremely  prob- 
able that  hallucinations  of  coitus,  and  the  complaints  made  by  in- 
sane women  of  attempted  violation  during  the  night,  are  really 
dependent  upon  such  "  pollutions." 

yon  Krafft-Ebing  reports  the  following  characteristic  case.  Miss 
X.,  thirty  years  of  age,  belonging  to  a  family  predisposed  to  in- 
sanity, and  herself  neuropathic  since  early  childhood,  declared  that 
since  she  was  six  years  old  she  had  been  subject  to  lascivious 
imaginations,  to  which  she  became  continually  more  liable  as  she 
grew  older.  Ultimately,  typical  psychical  onanism  developed,  and 
in  recent  years  her  trouble  assumed  the  form  of  sexual  neurasthe- 
nia. The  patient  herself  suspected  there  was  a  connection  between 
her  nervous  disorder  and  her  evil  habit.  The  popular  work  by 
Bock  finally  brought  her  full  enlightenment,  associated  with  severe 
emotional  disturbance.  This  latter  was  now  increased  by  misfortunes 
from  which  the  family  suffered.  The  patient  then  relinquished  her  bad 
habit,  but  her  state  of  health  nevertheless  became  worse.  She  was 
nervously  extremely  irritable ;  her  sleep  was  insufficient,  un- 
refreshing,  and  disturbed  by  lascivious  dreams;  she  suffered  from 
spinal  irritation,  anaemia,  scanty  and  painful  menstruation.  Inclina- 
tion toward  the  opposite  sex  and  toward  marriage,  hitherto  but 
slight,  now  sank  to  a  minimum:  on  the  other  hand,  the  patient,  in 
spite  of  all  efforts  to  the  contrary  became  more  and  more  subject 
to  a  condition  analogous  to  priapism  in  the  male,  a  genital  orgasm 
by  no  means  voluptuous  in  character,  and  often  indeed  actually 
painful.  Associated  therewith,  nocturnal  pollutions  occurred,  the 


354  THE  SEXUAL  LIFE  OF  WOMAN. 

patient  awaking  from  lascivious  dreams  with  a  voluptuous  sensa- 
tion and  moistness  of  the  external  genital  organs.  After  such  pollu- 
tions, throughout  the  ensuing  day,  she  felt  extremely  weary  and 
depressed  and  suffered  from  severe  spinal  irritation.  After  a  time, 
the  nocturnal  pollutions  occurred  without  being  preceded  by  lasciv- 
ious dreams,  and  ultimately  analogous  states  were  experienced  in 
the  daytime.  With  much  difficulty  the  patient  now  made  up  her 
mind  to  seek  medical  advice.  She  was  anaemic,  emaciated, 
emotional,  and  moody.  The  lumbar  and  cervical  regions  of  the 
spine  were  extremely  sensitive  to  pressure.  Sleep  was. scanty  and 
unref reshing,  the  patient  felt  weary  and  miserable,  she  complained 
of  dragging  sensation  and  other  paralgic  sensations,  in  the  regions 
supplied  by  the  lumbar  and  sacral  plexuses.  The  deep  reflexes  were 
increased.  She  dreaded  the  onset  of  disease  of  the  spinal  cord,  and 
believed  that  the  cause  of  her  illness  was  to  be  found  in  the  pro- 
longed indulgence  in  psychical  onanism.  The  perusal  of  Bock's 
book  had  first  made  her  understand  the  true  nature  of  her  miscon- 
duct. She  had  never  practised  manual  masturbation.  Her  prin- 
cipal complaint  was  of  an  almost  unceasing  uneasiness  and  excite- 
ment in  the  genital  organs.  She  compared  it  to  the  uneasiness  in 
the  stomach  produced  by  hunger.  In  the  genital  organs  (which  on 
examination  appeared  quite  normal),  she  had  a  distressing  sense 
of  burning  heat,  of  pulsation,  of  disquiet  as  if  there  were  a  clock- 
work mechanism  working  there.  Very  rarely  now  were  these  sen- 
sations associated  with  voluptuous  ideas.  This  sexual  neurosis  had 
an  intensely  depressing  constitutional  effect.  She  had  transient 
relief  only  when  the  local  sensations  culminated  in  pollution;  but 
this,  on  the  other  hand,  increased  her  general  neuropathic  troubles. 
She  suffered  most  severely  during  the  menstrual  period.  She  was 
ordered  sitz-baths  at  a  temperature  of  23°  to  19°  R.  (84°  to  75°  F.), 
suppositories  of  monobromide  of  camphor,  0.6  (9  grains),  with  extr. 
belladon.  0.04  (tys  gr.),  sodium  bromide  3.0  to  4.0  (45  to  60 
grains),  every  evening;  also  powders  containing  camphor  o.i  (il/t 
grains),  lupulin  0.5  (fy  grain),  extr.  secal  0.08  (i^4  grains), 
twice  daily.  This  treatment  gave  the  patient  great  relief,  and 
secured  complete  ease  during  the  daytime.  Therewith  returned  her 
greatly  impaired  trust  in  the  future,  and  her  emotional  calm  was 
restored. 

The  frequent  occurrence  of  pollutions  in  women,  the  so-called 
vulvo-vaginal  crises  and  clitoris-crises,  is  regarded  by  Eulcnbnrg 
as  a  striking  manifestation  of  sexual  neurasthenia  in  woman;  in 


THE  SEXUAL  EPOCH  OF  THE  MENACME.  355 

such  cases  a  lascivious  dream  is  spontaneously  followed  by  a  more 
or  less  abundant  discharge  of  the  clear  gelatino-mucous  secretion 
of  Bartholin's  glands.  In  women  who  masturbate,  and  in  tribadists, 
a  profuse  and  even  violent  secretion  of  these  glands  is  produced  by 
touching  the  clitoris  or  the  erogenic  zones  at  the  entrance  to  the 
vagina,  close  to  the  orifices  of  Bartholin's  ducts. 

Dyspareunia,  the  absence  of  voluptuous  sensation  in  women 
during  coitus,  may  be  referred  to  three  fundamental  causes: 

1.  Insufficient  or  completely  wanting  peripheral   stimulation  of 
the  sensory  nerve  terminals  in  the  female  reproductive  canal:  in 
these  cases  the  conducting  tracts  to  the  nerve  centres  never  become 
active. 

2.  Diminution  or  cessation  of  the  excitability  of  the  reflex  centre 
in  the  lumbar  enlargement  of  the  spinal  cord:  this  leads  to  failure 
of  the  sensation  of  ejaculation. 

3.  Inhibitory    influences    proceeding    from   the    cerebral    cortex 
whereby  voluptuous  sensations  and  perceptions  are  checked. 

The  first-named  of  these  etiological  influences  is  in  my  experi- 
ence the  commonest.  Incomplete  or  quite  inadequate  stimulation  of 
the  sensory  nerves  of  the  genital  canal  may  be  due  to  the  maladroit 
performance  of  copulation  on  the  part  of  the  male,  owing  to  inex- 
perience, or  it  may  depend  on  gross  disproportion  in  size  between 
the  reproductive  organs  of  the  man  and  the  woman;  in  other  cases 
it  may  be  due  to  disease  of  the  reproductive  organs  in  either  sex, 
influencing  unfavourably  the  sensibility  to  stimulation  of  the  nerves 
of  the  genital  canal.  Awkward  or  incomplete  performance  of 
coitus  may  thus  lead  to  failure  of  voluptuous  sensation,  and  this 
may  ultimately  pass  into  permanent  dyspareunia.  Temporary  dys- 
pareunia  is  very  common  in  young  wives  during  the  first  months 
of  married  life,  ensuing  on  the  pains  of  defloration;  and  very  grad- 
ually gives  place  to  normal  voluptuous  sensation.  It  may  be  one 
or  two  years  after  marriage  before  the  sensation  of  ejaculation  is 
first  experienced.  Not  infrequently,  dyspareunia  depends  on  in- 
complete potency  in  the  husband,  who  is  incompetent  to  arouse 
voluptuous  sensation  in  his  wife.  For  this  reason,  dyspareunia  is 
common  in  young  women  married  to  elderly  men;  but  is  common 
also,  where  (as  so  frequently  among  Russo-Polish  Jews)  the  men 
also  marry  very  young,  at  an  age  of  from  sixteen  to  seventeen  years, 
and  where,  moreover,  the  husband  has  often  before  marriage  im- 
paired his  potency  by  masturbation:  finally  dyspareunia  is  common 
when  girls  still  undeveloped  sexually  are  married  to  powerfully 
built  men. 


356"  THE  SEXUAL  LIFE  OF  WOMAN. 

Regarding  the  pathological  conditions  of  the  female  reproductive 
organs  which  counteract  the  peripheral  sensory  excitants  of  volup- 
tuous sensation,  we  exclude  from  further  consideration  the  obvious 
causes,  absence  and  atrophy  of  the  reproductive  organs,  and  senile 
marasmus.  Of  prime  importance  as  a  cause  of  the  failure  of  sexual 
sensibility  in  the  early  period  of  married  life  must  be  mentioned 
inflammation  of  the  fossa  navicularis,  due  to  awkward  attempts  at 
intercourse.  Other  causes  of  deficient  sensibility  are:  complete  or 
partial  persistence  of  the  hymen,  lesions  of  the  vaginal  inlet,  acute 
or  chronic  vulvitis  in  consequence  of  irritating  abundant  secretion, 
especially  as  a  sequel  of  gonorrhoeal  vaginitis.  The  last  named  in- 
fective disorder  is  especially  harmful,  because  Bartholin's  glands 
are  involved  in  the  associated  vulvitis.  Even  after  the  cure  of  the 
vulvitis,  permanent  dyspareunia  may  remain.  Perineal  fissures  may 
result  in  the  stimulant  effect  of  coitus  being  insufficient,  owing  to 
the  slight  friction  possible  at  the  vaginal  inlet  in  these  cases.  Not 
less  serious  sometimes  are  small,  hardly  discernible  fissures  in  the 
vagina.  Additional  causes  of  deficient  sexual  sensibility  are  recto- 
vaginal,  and  vesico-vaginal  fistulae. 

The  second  cause  of  dyspareunia,  diminution  or  complete  lack 
of  irritability  of  the  reflex  centre  of  the  lumbar  enlargement  of 
the  spinal  cord,  appears  to  be  less  frequently  operative.  We  must, 
however,  assume  that  certain  nervous  disorders,  such  as  hysteria 
and  pathological  changes  in  the  spinal  cord,  are  responsible  in  this 
connection.  The  activity  of  the  lumbar  sexual  centre  appears  in 
women  to  be  normally  subject  to  variation  within  certain  limits; 
and  seems  usually  to  attain  its  maximum  irritability  during  men- 
struation. But  normally  these  variations  are  never  so  great  as  to  pro- 
duce in  women  complete  though  merely  temporary  dyspareunia;  in 
this  respect  offering  a  marked  contrast  to  what  occurs  in  other 
animals  at  other  times  than  the  rutting  season,  and  of  which  every 
bitch  not  on  heat  furnishes  an  example  when  she  refuses  the  sexual 
advances  of  the  dog. 

As  regards  the  third  causal  influence  in  the  production  of  dys- 
pareunia, the  influence  of  the  brain,  this,  though  important,  is  less 
frequently  in  operation.  Diseases  of  the  brain,  degenerative  proc- 
esses, may  constitute  a  cerebral  cause  for  the  failure  of  sexual 
sensation.  But  more  frequently,  certain  cortical  perceptions,  such 
as  dislike  or  hatred  of  the  cohabiting  male,  an  ardent  passion  for 
some  other  lover,  grief  and  trouble,  exercise  inhibitory  influences, 
which  render  the  occurrence  of  voluptuous  pleasure  during  the 
sexual  act  difficult  or  quite  impossible. 


THE  SEXUAL  EPOCH  OF  THE  MENACME.  357 

A  condition  like  dyspareunia,  our  knowledge  of  which  depends 
entirely  upon  the  subjective  sensations  of  the  woman  concerned,  is 
naturally  one  regarding  whose  existence  accurate  information  is 
difficult  to  obtain.  Very  rarely  does  it  happen  that  women  spon- 
taneously approach  the  physician  with  complaints  of  this  condi- 
tion; indeed,  in  my  experience,  they  do  so  only  when  they  are 
sterile,  and  when  they  assume,  in  accordance  with  the  widespread 
popular  belief,  that  their  sterility  is  connected  with  the  absence  of 
voluptuous  sensation  during  sexual  intercourse.  More  commonly, 
however,  it  is  the  husband  who  feels  it  his  duty  to  confide  to  the 
medical  man  the  remarkable  apathy  of  his  wife  in  sexual  inter- 
course. But  when  once  the  medical  man's  attention  has  been 
directed  to  this  question,  and  when  he  institutes  enquiries  among 
his  patients  in  a  scientific,  passionless  manner,  one  making  due  al- 
lowance for  a  woman's  modesty,  as  the  moral  importance  of  the 
subject  demands,  he  will  be  astonished  at  the  frequency  of  dyspa- 
reunia, and  he  will  find  herein  the  explanation,  of  many  obscure 
phenomena  in  the  life  of  women.  On  the  other  hand,  it  must  never 
be  forgotten  that  a  certain  number  of  women  complain  of  dyspa- 
.reunia  without  any  justification  whatever,  in  order  to  arouse  inter- 
est and  sympathy,  by  representing  themselves  as  unwilling  sacri- 
fices on  the  marital  altar :  the  experienced  gynecologist  will  readily 
detect  the  cases  in  which  he  is  being  misinformed;  he  can,  more- 
over, always  check  the  wife's  statements  by  conversation  with  the 
husband. 

The  constant  sign  of  dyspareunia  is  the  failure  of  ejaculation 
during  coitus.  We  have  previously  described  the  muscular  con- 
tractions which  lead  to  ejaculation  of  the  secretion  of  Bartholin's 
glands  and  to  the  expulsion  of  the  uterine  and  cervical  mucus, 
as  reflex  actions  evoked  by  the  sensory  stimulus  dependent  on 
friction  of  the  female  genital  organs.  The  voluptuous  sensation  of 
ejaculation,  associated  with  these  muscular  contractions,  which  the 
woman  whose  sensibility  is  normal  experiences  as  the  culminating 
point  of  her  sexual  "  gratification,"  is  either  quite  unknown  to  a 
woman  affected  by  dyspareunia,  or  is  experienced  by  her  only  in  a 
voluptuous  dream,  as  a  pollution,  in  which  the  sexual  dream- 
perceptiens  act  as  the  psychical  stimuli  by  which  the  reflex  dis- 
charge is  originated.  It  has  repeatedly  happened  to  me,  that  on 
enquiring  of  women  suffering  from  dyspareunia  regarding  their 
experience  of  the  sensation  of  ejaculation,  I  have  been  informed 
that  such  sensations  are  known  to  them  only  from  the  descriptions 
of  their  female  friends,  or  occasionally  from  dreams  from  which 


358  THE  SEXUAL  LIFE  OF  WOMAN. 

they  have  awakened  with  a  feeling  of  moisture  in  the  external  geni- 
tals. Von  Krafft-Ebing  refers  this  process  to  a  peristaltic  contrac- 
tion of  the  muscular  fibres  of  the  Fallopian  tubes  and  the  uterus, 
"  whereby  the  tubal  and  uterine  mucus  is  expressed ;"  whereas,  for 
.my  part,  I  am  of  opinion,  that  ejaculation  affects  in  the  first  place 
and  principally  the  glands  of  Bartholin,  the  secretion  of  which  is 
expressed  by  the  contraction  of  the  constrictor  cunni  muscles,  and 
secondarily  only  affects  the  cervical  glands  of  -the  uterus. 

As  a  second  sign  of  dyspareunia,  I  recognize  a  remarkably  rapid 
outflow  of  the  male  semen  from  the  female  genital  canal,  imme- 
diately after  coitus  (profluvium  seminis} .  The  woman  thus  affected 
complains,  when  suitably  questioned,  that  she  is  unable  to  retain 
the  semen,  and  that  it  flows  out  of  the  vagina  immediately  after 
ejaculation.  The  cause  of  this  remarkable  phenomenon  no  doubt 
lies  in  the  fact,'  that,  owing  to  the  absence  of  the  voluptuous  sensa- 
tion, the  reflex  contractions  of  the  muscles  of  the  female  genital 
organs,  normally  accompanying  this  sensation  during  intercourse, 
fail  to  occur.  At  the  vaginal  inlet,  in  normal  conditions,  the  con- 
strictor cunni  muscle  contracts,  and  farther  up  in  the  vagina  a 
peristaltic  contraction  of  the  circularly  disposed  muscular  fibres 
of  the  tunica  media  occurs:  in  this  way  the  semen  ejaculated  into 
the  vagina  is  for  a  time  retained  under  a  certain  pressure.  But  in 
the  absence  of  these  muscular  contractions,  as  well  as  of  the  mus- 
cular contraction  of  the  pelvic  floor,  retention  of  the  semen  fails 
to  occur.  Cattle-breeders  and  horse-breeders  have  made  similar 
observations  regarding  cows  and  mares,  namely,  that  these  animals 
are  sometimes  unable  to  retain  the  semen  after  coitus,  and  it  is 
suggested  that  in  these  cases  the  animals  are  not  properly  on  heat. 
Experienced  cattle-breeders  recommend  in  such  cases  that  the  re- 
tention of  the  semen  should  be  promoted  by  douching  the  root  of 
the  tail  and  the  external  genitals  with  cold  water.  It  is  well  known 
that  by  stimulating  the  peripheral  sensory  nerves  in  the  neighbour- 
hood of  the  genital  organs,  a  reflex  excitement  of  the  lumbar  sexual 
nerve  centre  is  produced,  as  is  seen,  for  example,  in  the  practice 
of  flagellation  of  the  buttocks,  for  the  increase  of  sexual  desire. 

Passing  to  the  consideration  of  the  pathological  changes  to  be 
found  in  the  reproductive  organs  of  women  suffering  from  dyspa- 
reunia, the  nature  of  these  will  for  the  most  part  be  obvious  in  rela- 
tion to  the  etiology  of  the  disorder.  Most  frequent,  in  my  experi- 
ence, were  chronic  inflammatory  states  of  the  vulva  and  of  the 
vaginal  and  uterine  mucous  membrane,  chronic  metritis  and  para- 


THE  SEXUAL  EPOCH  OF  THE  MENACME.  359 

metritis.  A  very  frequent  appearance,  and  one  practically  charac- 
teristic of  dyspareunia  when  of  long  standing,  is  a  marked  total 
relaxation  of  the  reproductive  apparatus.  The  uterus  is  extremely 
mobile,  usually  retroverted  and  partially  prolapsed,  thin,  with  lax 
walls,  and  usually  an  enlarged  cavity ;  the  portio  vaginalis  is  flaccid, 
and  runs  to  a  point;  the  vagina  is  roomy;  there  is  marked  hyper- 
secretion  of  the  mucous  membrane  of  the  entire  genital  canal; 
there  is  great  flaccidity  of  the  constrictor  cunni  and  levator  ani 
muscles,  and  of  the  perineum.  In  several  women  with  dyspareunia, 
I  found  old  unhealed  lacerations  of  the  perineum.  In  some  cases, 
the  very  small  size  of  the  clitoris  is  noteworthy.  In  one  case 
amenorrhoea  was  present  with  an  infantile  uterus.  In  a  large  pro- 
portion of  the  cases  I  was  able  to  .detect  a  diminution  both  of  the 
tactile  and  algic  sensibility  of  the  vaginal  mucous  membrane.  The 
women  were  for  the  most  part  anaemic;  many  were  extremely 
obese,  and  of  lymphatic  constitution.  In  some  cases,  however,  no 
pathological  changes  whatever  could  be  detected  in  the  reproductive 
apparatus. 

Dyspareunia  is  a  condition  which  affects  a  woman's  whole  nature, 
powerfully  influences  her  mental  life,  and  thus  gives  rise  to  greater 
psychical  than  physical  damage.  The  consciousness  of  being  de- 
prived of  the  greatest  joy  of  physical  love  produces  great  emo- 
tional depression,  even  in  a  woman  by  no  means  sensually  inclined, 
and  gives  rise  to  a  hypochondriacal  state,  at  times  even  to  melan- 
cholia. In  other  cases,  the  idea,  not  infrequently  suggested  by 
more  happily  situated  women  friends,  that  the  woman  herself  is 
not  to  blame  for  this  condition,  has  a  demoralizing  effect  upon  her, 
and  destroys  the  happiness  of  married  life.  (It  has  been  confessed 
to  me,  in  isolated  cases,  that  the  dyspareunia  was  relative  only.) 
.  Apart  from  this,  the  absence  of  sexual  gratification  gives  rise  to  a 
series  of  nervous  troubles,  presenting  either  the  variable  characters 
of  hysteria,  or  else  the  symptoms  of  neurasthenia.  Finally,  the  fre- 
quently repeated  incomplete  coitus,  incomplete  inasmuch  as  the 
woman  does  not  experience  the  sensation  of  ejaculation,  induces 
chronic  hyperaemia  in  the  female  reproductive  organs,  passing  on 
into  blood  stasis,  and  ultimately  into  chronic  inflammatory  tissue 
changes;  in  this  way  arise  metritis,  perimetritis,  and  parametritis, 
salpingitis,  oophoritis,  disorders  of  menstruation,  menorrhagia,  and 
atypical  uterine  haemorrhages.  The  possibility  cannot  be  disproved, 
that  in  this  way  new-growths  of  the  reproductive  organs  may  also 
originate.  The  act  of  sexual  intercourse,  which  at  first  may  be  to 


360  THE  SEXUAL  LIFE  *,?  WOMAN. 

the  woman  a  matter  of  comparative  indifference,  and  in  which  she 
plays  her  part  merely  from  a  sense  of  duty,  becomes,  in  cases  of 
long-standing  dyspareunia,  something  to  which  she  feels  a  positive 
dislike,  and  is  recognized  by  her  as  the  actual  cause  of  the  troubles 
that  ensue  upon  intercourse,  such  as  sacrache,  sensations  of  weight 
and  pressure  /n  the  pelvis,  strangury,  fluor  albus,  a  feeling  of  ex- 
haustion, etc. 

At  times,  perverse  sexual  sensation  is  associated  with  dyspa- 
reunia. Women  who  find  no  enjoyment  in  normal  sexual  inter- 
course with  a  male,  sometimes  masturbate,  sometimes  indulge  in 
amor  lesbicus,  etc. 

Of  great  importance  appears  to  me  the  relation  between  dyspa 
reunia  and  sterility  in  women.  As  already  pointed  out,  dyspareunia 
comes  chiefly  under  medical  observation  in  cases  in  which  it  is 
associated  with  sterility.  The  husband,  seeking  advice  concerning 
his  wife's  failure  to  conceive,  complains  of  her  frigidity  in  sexual 
intercourse  as  the  probable  cause ;  or  the  wife  comes  to  seek  ad- 
vice, saying  that  she  never  experiences  sexual  gratification,  and 
that  for  this  reason  she  has  failed  to  become  pregnant.  As  a  matter 
of  actual  fact,  dyspareunia  and  sterility  are  associated  with  such 
remarkable  frequency,  that  my  own  experience  leads  me  to  be- 
lieve in  the  existence  of  an  etiological  connection  between  the  two 
conditions,  at  least  in  a  certain  proportion  of  the  cases.  Among 
69  sterile  women  whom  I  questioned  regarding  dyspareunia,  the  lat- 
ter condition  was  present  in  26,  that  is  to  say,  in  38$  of  the  cases. 
Matthews  Duncan  reported  that  of  191  sterile  women,  62  did  not 
experience  sexual .  enjoyment.  Sexual  excitement  of  the  woman 
during  copulation  would  certainly  appear  to  have  a  definite  bearing 
upon  the  occurrence  of  conception,  for  we  know  that  by  the  volup- 
tuous sensation  reflex  actions  are  aroused  in  the  genital  canal, 
favouring  the  retention  of  semen  and  its  passage  through  the  os  to 
the  interior  of  the  uterus,  and  perhaps  also  giving  rise  to  reflex 
changes  in  the  cervical  secretion  which  favour  the  passage  of  the 
spermatozoa  into  the  uterine  cavity. 

In  cases  of  relative  dyspareunia,  the  influence  of  this  condition 
m  producing  sterility  is  also  manifested,  the  unfaithful  wife  being 
impregnated  by  her  lover  though  she  has  remained  sterile  in  inter- 
course with  the  husband  to  whom  she  is  indifferent.  To  dyspa- 
reunia of  this  nature  (dependent  upon  sexual  disharmony),  we 
may  also  refer  the  sterility  of  a  married  pair  who  have  for  some 
time  lived  together  in  unfruitful  intercourse,  whereas,  after  divorce 
2nd  the  contraction  of  fresh  unions,  both  the  man  and  the  woman 


THE.  SEXUAL  EPOCH  OF  THE  MEIJACME.  361 

prove  normally  fertile.  Such  cases  have  been  personally  known 
to  me;  and  similar  instances  aroused  the  attention  of  the  natural 
philosophers  of  antiquity,  for  instance,  that  of  Aristotle.  The  im- 
portance of  voluptuous  sensation  in  promoting  conception  is  also 
manifest  from  the  fact  that  in  the  majority  of  women,  after  the 
pains  of  defloration,  dyspareunia  usually  persists  for  a  season  during 
the  early  period  of  married  life;  and,  corresponding  with  this,  the 
first  conception  is  usually  deferred  for  some  little  time  after  mar- 
riage, to  a  period  corresponding  with  the  awakening  of  the  sen- 
sation of  ejaculation.  In  this  connection,  Courty  reports  the  case 
of  a  lady  who,  although  in  blooming  health,  remained  sterile  during 
the  first  fifteen  years  of  ,her  married  life;  she  then  gave  birth  to 
a  child  whose  father  was  unquestionably  her  lover;  and  after  this 
in  succession  to  two  other  children  whose  progenitor  was  the  legal 
husband.  This  lady  had  never  experienced  voluptuous  sensation 
in  intercourse  prior  to  the  time  of  her  first  conception.  Similar 
circumstances  with  an  even  clearer  significance  have  been  fre- 
quently observed  among  the  lower  animals ;  and  Darwin  records 
several  striking  observations  of  this  character.  Taking  all  the 
evidence  into  consideration,  we  are  compelled  to  regard  dyspareunia 
as  a  condition  capable  of  causing  sterility  in  women,  although  the 
sequence  is  not  an  absolutely  necessary  or  invariable  one. 

In  order  to  excite  voluptuous  sensation  during  intercourse,  sav- 
age races  make  use  of  various  means,  some  of  which  we  here 
transcribe  from  the  work  of  Ploss-Bartels.  In  Abyssinia,  and  on 
the  Zanzibar  coast,  young  girls  receive  instruction  in  certain  rotary 
muscular  movements  known  by  the  name  of  duk-duk,  which  they 
employ  during  coitus  for  the  increase  of  sexual  pleasure.  Many 
Daiaks  perforate  the  glans  penis  with  a  silver  needle  from  above 
downwards ;  this  needle  is  kept  in  place  like  a  seton,  until  a  per- 
manent canal  is  formed  through  the  glans:  in  order  during  coitus 
to  stimulate  the  woman  more  powerfully,  into  this  canal,  just 
before  coitus,  various  small  articles  are  inserted,  such  as  little 
rods  of  brass,  ivory,  silver,  or  bamboo,  or  silver  instruments  end- 
ing in  small  bundles  of  bristles ;  these  project  from  the  surface  of 
the  glans,  and  exercise  a  more  powerful  friction  of  the  vagina, 
thus  increasing  the  sexual  pleasure  of  the  woman.  Men  without 
such  an  apparatus  are  rejected  by  the  women,  whilst  those  who 
have  made  several  such  canals  in  the  glans,  and  can  therefore  in- 
sert several  instruments,  are  especially  sought  after  and  prized  by 
the  women.  Such  an  apparatus  is  known  as  an  ampallang,  and 


362  THE  SEXUAL  LIFE  OF  WOMAN. 

in  a  symbolic  manner  the  woman  indicates  to  a  man  of  her  choice 
her  desire  that  he  should  make  use  of  one ;  he  finds  in  his  bowl 
of  rice  a  rolled-up  leaf,  enclosing  a  cigarette  which  represents  the 
size  of  the  desired  ampallang.  Among  the  Alfurs  of  North  Cele- 
bes, in  order  to  increase  the  voluptuous  pleasure  of  the  woman 
during  intercourse,  the  men  bind  round  the  corona  glandis  the 
eyelids  of  a  goat,  beset  with  the  eyelashes,  thus  forming  a  bristly 
collar;  in  Java  and  in  Sunda,  before  coitus,  the  men  surround  the 
penis  with  strips  of  goat-skin,  leaving  the  glans  free.  In  China  they 
wind  round  the  corona  glandis  torn  fragments  of  a  bird's  wing; 
these  also  project  like  bristles  and  increase  the  friction.  Among 
the  Batta  of  Sumatra,  travelling  medicine-men  perform  an  opera- 
tion by  means  of  which  they  insert,  beneath  the  skin  of  the  penis, 
small  stones,  sometimes  to  the  number  of  ten,  at  times  also  angular 
fragments  of  gold  or  silver;  these  heal  in  beneath  the  skin,  and 
increase  the  stimulus  of  coitus  for  the  women.  Among  the  Malays 
of  Borneo  the  penis  is  perforated,  and  some  fine  brass  wire  with 
the  ends  turned  inwards  is  inserted:  before  coitus,  the  sharp  ends 
of  the  wire  are  drawn  out  so  as  to  project  from  the  skin. 

In  our  own  part  of  the  world,  voluptuaries  make  use  of  an  india- 
rubber  ring  beset  with  spines,  which  before  coitus  is  passed  over 
the  corona  glandis,  in  order  to  promote  sexual  gratification  in  the 
woman  during  intercourse.  In  cases  of  diminished  potency  in  the 
male,  in  order  to  produce  sufficient  sexual  excitement  in  the  female 
by  more  powerful  erection  of  the  penis,  various  mechanical  means 
are  now  employed.  For  instance,  in  such  a  partially  impotent 
man,  a  constricting  band  of  india-rubber  may  be  passed  over  the 
root  of  the  penis,  whereby  the  reflux  of  blood  from  the  corpora 
cavernosa  is  hindered,  and  a  more  complete  and  more  enduring 
erection  is  induced.  Elderly  men  have  frequently  declared  to  me 
that  they  were  well  satisfied  by  the  employment  of  this  simple 
measure,  whilst  behind  their  backs,  their  wives  have  assured  me 
that  the  results  were  far  from  satisfactory.  The  apparatus  de- 
scribed by  Roubaud  for  the  enlargement  of  the  penis  is  no  longer 
employed.  Partially  impotent  men  make  use,  however,  of  an  in- 
strument known  by  the  name  of  "  schlitten,"  made  of  gold,  silver, 
or  white-metal;  it  consists  of  two  delicate  laminae,  united  at  the 
base  by  a  metal  ring,  and  at  the  upper  end  by  an  india  rubber  ring. 
This  small  apparatus,  which  must  be  made  exactly  to  measure,  ren- 
ders possible  the  introduction  of  the  imperfectly  erect  penis  into 
the  vagina;  it  supports  the  penis,  and  readily  accommodates  itself 
to  the  change  in  size  of  the  organ  as  it  slowly  becomes  erect. 


THE  SEXUAL  EPOCH  OF  THE  MENACME.  363 

FERTILITY  IN  WOMEN. 

Fertility  in  women  is  the  basis  of  the  fecundity  of  a  nation,  of 
its  growth,  its  power,  and  its  importance.  It  is  especially  the 
fertility  of  married  women  which  enters  here  into  consideration, 
and  forms  the  source  of  the  statistical  data  of  fertility;  these  are 
usually  obtained  by  drawing  a  ratio  between  the  number  of  mar- 
riages contracted  in  a  given  period,  and  the  number  of  children 
born  in  the  same  period. 

The  fertility  of  women  is  a  function  beginning  at  an  age  vary- 
ing in  dependence  on  many  conditions,  and  undergoing  extinction  at 
a  definite  period  of  life.  It  is,  in  fact,  associated  with  the  duration 
of  the  sexual  life  of  woman,  and,  generally  speaking,  extends 
from  the  sixteenth  to  the  fiftieth  year  of  life.  Climate, 
race,  constitution,  and  morbid  conditions,  influence  alike  the  first 
appearance  of  menstruation  and  the  first  pregnancy;  and  as  they 
influence  the  duration  of  menstrual  activity,  so  also  do  they  in- 
fluence the  duration  of  fertility. 

In  the  Bible  are  recorded  numerous  instances  of  the  early 
commencement  of  fertility.  At  the  present  time  also,  in 
warm  climates  we  meet  with  many  examples  of  early  mother- 
hood. From  the  great  -work  of  Ploss-Bartels,  from  which  we 
have  already  frequently  quoted,  we  extract  and  summarize  the 
following  ethnographical  details.  Among  the  wives  of  the  Bos- 
jesman,  mothers  aged  ten  are  frequently  seen ;  travellers  in  New 
Zealand  often  saw  mothers  of  eleven  years,  and  mothers  of  the 
same  age  among  the  Samoyedes  and  in  Palestine ;  mothers  of 
twelve  in  British  Guiana,  in  Jamaica,  among  the  Schangallas,  at 
Shiraz  in  Persia,  among  the  Copts  in  Egypt ;  mothers  aged  thir- 
teen in  Cuba,  among  the  Sioux  and  the  Dakotas,  and  in  New 
Caledonia ;  mothers  aged  fourteen  among  the  Negroes  of  Gaboon. 

According  to  the  observations  of  Robertson,  of  sixty-five  Indian 
women  there  gave  birth  for  the  first  time: 

At  the  age  of  10  years r 

At  the  age  of  1 1  years 4 

At  the  age  of  1 2  years J  * 

At  the  age  of  13  years n 

At  the  age  of  i  4  years 1 8 

At  the  age  of  1 5  years . . :    :    12 

At  the  age    of  1 6  years 7 

At  the  age  of  I  7  years I 

Moreover,  in  the  records  of  European  countries,  we  find  numer- 
ous instances  of  very  early  motherhood.  Mentor's  case,  a  girl  nine 


364  THE  SEXUAL  LIFE  OF  WOMAN. 

years  old  giving  birth  to  a  vesicular  mole  with  an  embryo;  von 
Hatter's  case,  pregnancy  in  the  ninth  year  of  life;  Cams'  case, 
pregnancy  at  the  age  of  eight.  Caspar  saw  a  girl  in  Berlin  who 
became  pregnant  at  the  age  of  twelve,  and  was  delivered  of  a 
living  child.  Rilttel  saw  a  girl  nine  years  of  age  pregnant.  King 
attended  the  confinement  of  a  girl  who  at  the  time  of  her  delivery 
was  not  yet  eleven  years  old.  Taylor  reports  the  case  of  a  girl 
twelve  years  and  six  months  of  age  who  was  then  in  the  last  month 
of  pregnancy.  Koblanck  attended  a  girl  of  fourteen  who  was 
delivered  of  a  child  weighing  four  and  a  half  pounds. 

In  most  of  these  cases  the  premature  fertility  is  followed  by  a 
premature  cesssation  of  fertility.  And  there  is  more  or  less  truth 
in  Bruce' s  statement  regarding  the  Arab  women  in  Africa,  that 
those  who  began  to  bear  children  at  the  age  of  eleven  were  seldom 
still  fertile  at  the  age  of  twenty. 

At  times  we.  may  observe  a  remarkable  extension  of  fertility  be- 
yond the  average  age,  that  is,  beyond  the  age  of  fifty  years. 

In  northern  Europe  pregnancy  at  a  comparatively  advanced  age 
is  by  no  means  rare.  From  the  official  statistics  of  Denmark  we 
learn  that  among  10,000  women,  465  were  delivered  at  ages  be- 
tween 50  and  55  years.  In  Sweden,  of  10,000  mothers,  300  gave 
birth  to  children  when  more  than  50  years  of  age.  In  Ireland,  the 
proportion  of  mothers  over  50  was  345  per  10,000.  In  England 
the  official  figures  dealing  with  the  delivery  of  483,613  women, 
showed  that  7,022  were  between  45  and  50  years  of  age,  and  167 
over  50  years  of  age. 

The  Surgical  Academy  of  Paris,  in  an  authoritative  statement 
regarding  the  late  age  at  which  conception  could  take  place,  alluded 
to  the  fact  that  Cornelia,  of  the  family  of  the  Scipios,  gave  birth 
to  Volusius  Saturninus  when  sixty  years  of  age,  that  the  physician 
Marsa  in  Venice  recorded  the  existence  of  pregnancy  in  a  woman 
of  sixty,  that  de  la  Motte  recorded  pregnancy  in  a  woman  of  fifty- 
one,  and  that  he  believed  it  to  be  true  that  another  Parisian  woman 
had  given  birth  to  a  girl  at  the  age  of  sixty-three,  and  had  herself 
suckled  the  infant. 

In  an  important  case,  however,  which  came  before  the  Court  of 
Chancery  in  England,  the  court  held  that  there  was  no  definite 
evidence  of  the  possibility  of  pregnancy  in  a  woman  sixty  years 
of  age;  but  that  the  greatest  age  at  which,  in  England,  pregnancy 
had  indisputably  occurred,  was  54. 

Among  4,925  deliveries  occurring  in  the  Prague  Maternity  Hos- 


THE  SEXUAL  EfCcii  OF*  THE  MENACME.  365 

pital,  Schwing  reports  that  there  were  9  women  delivered  for  the 
first  time  when  over  40  years  of  age.     Of  these: 

3  were  41  years  of  age. 
2  were  42  years  of  age. 

1  was    43  years  of  age. 

2  were  44  years  of  age. 
i  was    47  years  of  age. 

Holler  reports  the  cases  of  two  women  who  gave  birth  to  chil- 
dren, one  at  the  age  of  63,  the  other  at  the  age  of  70  years.  Meiss- 
ner  delivered  a  woman  of  60  years  of  her  seventh  child;  Rush 
attended  the  delivery  of  a  woman  aged  60;  Dczuces  that  of  a 
woman  aged  61.  Mende  and  Bernstein  report  cases  of  delivery 
at  the  age  of  60.  Marion  Sims  saw,  in  the  state  of  Alabama,  a 
negro  woman  58  to  60  years  of  age,  who  gave  birth  to  a  child  at 
this  age,  at  an  interval  of  twenty  years  since  her  last  pregnancy. 
Niedcn  reports  a  case  in  which  the  first  pregnancy  occurred  26 
years  after  marriage.  When  married,  the  wife  was  18  years'  of 
age,  the  husband  30;  during  their  first  twenty-five  years  of  married 
life  there  was  no  sign  of  pregnancy,  but  when  the  wife  was  44 
years  of  age,  menstruation,  hitherto  regular,  suddenly  ceased ;  the 
cause  of  the  cessation  proved  to  be  pregnancy,  and  at  term  a 
healthy  girl  weighing  nine  pounds  was  born ;  the  mother  was  able 
to  nurse  the  child  herself.  Smith  attended  a  woman  aged  52  who 
was  delivered  of  twins;  the  youngest  of  her  eight  other  children, 
who  were  then  all  living,  was  ten  years  of  age. 

Rodsczvitsch  collected  from  the  Russian  literature  of  the  years 
1872  to  1881,  eleven  cases  in  which  women  aged  50  to  55  had  given 
birth  to  children.  Talquist  reports  that  in  Finland,  in  the  year 
1883,  a  woman  58  years  of  age  was  delivered ;  whilst  Anscll  re- 
cords the  case  of  an  Englishwoman  who  became  a  mother  when 
59  years  of  age.  John  Kennedy  records  the  case  of  a  woman  of 
62  who  was  normally  delivered  at  this  age;  she  had  begun  to 
menstruate  at  the  age  of  13,  and  since  the  age  of  20  had  pre- 
viously given  birth  to  21  children,  the  last  five  when  she  was  47, 
49>  5T>  53>  and  S^  years  of  age,  respectively.  Prior  even  reports 
the  case  of  a  woman  72  years  of  age,  who  not  only  menstruated,  but 
had  an  abortion  (  !) 

The  ideal  of  fertility  in  women  is  that  the  first  completed  act  of 
•sexual  intercourse  should  be  followed  immediately  by  conception, 
that  the  pregnancy  should  terminate  after  the  normal  lapse  of 
time  in  the  birth  of  a  child,  and  that  the  same  process  should  be 


366  THE  SEXUAL  LIFE  OF  WOMAN. 

repeated  at  intervals  of  about  ten  months  until  the  end  of  active 
sexual  life.  In  actual  experience,  however,  this  never  occurs. 
Fertilization  as  an  immediate  consequence  of  the  first  act  of  sexual 
intercourse  (which  in  the  lower  animals  is  regarded  as  the  rule) 
is  a  very  rare  occurrence  in  human  beings.  Moreover,  in  no 
single  marriage  is  the  reproductive  capacity  of  the  wife  utilized 
to  the  full,  up  to  the  time  of  extinction  of  her  generative  faculty; 
either  because  the  potency  of  the  male  partner  undergoes  a  gradual 
decline,  or,  it  may  be,  because,  after  a  while,  sexual  intercourse 
becomes  less  frequent,  or  because  precautions  against  procreation 
are  taken. 

The  number  of  children  to  which  during  the  three  decades  of 
her  sexual  life,  from  the  menarche  to  the  menopause,  a  woman 
might  theoretically  give  birth,  is  never  actually  born.  If  we  as- 
sume that,  during  the  period  of  active  sexual  life,  a  woman  re- 
quires a  period  of  fifteen  months  to  two  years  for  each  pregnancy, 
parturition,  and  lactation,  a  woman  could  easily  during  this  period 
have  fifteen  or  sixteen  children,  and  this  figure  would  represent 
the  normal  product  of  the  normal  fertility  of  the  human  female. 
There  are  indeed,  women  who,  it  may  be  in  consequence  of  an 
exceptionally  long  period  of  sexual  activity,  or  through  giving 
birth  repeatedly  to  twins  or  triplets,  or  because  they  have  married 
several  husbands  in  succession,  have  given  birth  to  twenty- four 
children  or  even  more.  In  Berlin,  in  the  year  1901,  there  lived  a 
woman  41  years  of  age  who  had  had  23  children;  there  were  three 
women,  aged  respectively  40,  43,  and  46  years,  who  had  had  each  21 
children;  246  women  with  families  numbering  13  to  20;  and  169 
women  each  of  whom  had  given  birth  to  12  children.  In  the 
very  great  majority  of  cases,  however,  the  fertility  of  the  wife  of 
the  present  day  is  never  fully  developed.  It  is  modified  in  various 
ways  by  the  conditions  of  marriage,  by  social  circumstances,  by 
considerations  relating  to  the  health  of  husband  or  wife,  by  actual 
illnesses,  and  by  voluntary  limitation  of  fertility.  Generally  speak- 
ing, according  to  the  investigations  of  Quctclet,  Sadler,  and  Finlay- 
son,  the  fertility  of  women  is  greatest  in  marriages  in  which  the 
husband  is  as  old  as  the  wife,  or  a  little  older,  but  without  marked 
difference  in  age.  Marriages  contracted  at  a  very  early  age  are 
less  fruitful;  the  highest  fertility  is  found  in  marriages  contracted 
when  the  husband  is  23  and  the  wife  26  years  of  age. 

Conception  does  not  generally  take  place  until  sexual  intercourse 
has  been  frequently  repeated.  As  the  result  of  a  statistical  enquiry 


THE  SEXUAL  EPOCH  OF  THE  MENACME.  367 

of  my  own,  relating  to  556  fruitful  marriages,  I  ascertained  that  in 
these  the  first  delivery  occurred: 

Within  10  months  after  marriage  in  156  cases. 
Within  ii  to  15  months  after  marriage  in  199  cases. 
Within  1 6  to  24  months  after  marriage  in  115  cases. 
Within  2  to  3  years  after  marriage  in  60  cases. 
More  than  3  years  after  marriage  in  26  cases. 

Thus  we  learn  that  in  35.5%  of  the  cases  the  first  delivery  occurred 
within  i!<4  years  after  marriage;  in  15.6%  within  10  months;  and  in 
19.9%  within  15  months  after  marriage;  and  11.5%  of  the  cases,  the 
first  delivery  was  more  than  1*4  years  and  less  than  2  years  after 
marriage;  in  6.0%  it  was  between  2  and  3  years  after  marriage; and 
in  2.6%,  the  first  delivery  did  not  occur  until  more  than  3  years 
after  marriage. 

From  examination  of  the  birth  registers  of  Edinburgh  and  Glas- 
gow, Matthews  Duncan  determined  the  mean  interval  between  mar- 
riage and  the  birth  of  a  living-  child  to  be  seventeen  months.  In 
the  majority  of  cases,  the  first  delivery  does  not  occur  until  a  com- 
plete year  has  elapsed  since  marriage;  in  fact,  in  nearly  two-thirds 
of  the  instances  the  first  delivery  occurs  during  the  second  year  of 
married  life. 

The  interval  between  two  successive  births  is,  according  to 
Matthews  Duncan,  on  the  average  18  to  24  months,  according  to 
Goehlert,  24  to  26  months ;  the  latter,  however,  points  out  that  in 
cases  in  which  the  child  dies  very  soon  after  birth,  the  birth  of  the 
next  child  ensues  on  the  average  in  16  to  18  months.  In  this  con- 
nection, we  must  not  fail  to  take  into  consideration  the  influence 
of  lactation,  inasmuch  as  mothers  who  do  not  suckle  their  children 
become  pregnant  considerably  earlier,  on  the  average,  than  those 
who  undertake  this  duty.  In  reigning  families,  for  instance,  it  is 
by  no  means  uncommon  for  the  consort  to  be  delivered  twice 
within  a  single  year.  The  degree  to  which  lactation  hinders  concep- 
tion is  so  widely  known,  that  women  often  suckle  their  infant  for  a 
very  long  period,  with  the  definite  aim  of  preventing  the  speedy  re- 
currence of  pregnancy.  A  high  official  from  the  Dutch  Indies  in- 
formed me  that  for  this  reason  the  native  women  were  accustomed 
to  suckle  their  infants  for  several  years,  and  that  it  was  by  no 
means  uncommon  to  see  a  small  boy  running  about  smoking  a  cigar, 
and  then  hurrying  to  his  mother  in  order  to  be  suckled. 

The  age  at  which  a  woman  contracts  marriage  has  also  to  this 
extent  an  influence  upon  her  fertility,  inasmuch  as  it  appears  that 
those  who  marry  very  young  are  far  less  fertile  than  those  who 


THE  SEXUAL  LIFE  OF  WOMAN. 


marry  between  the  ages  of  20  and  25  years;  the  latter  moreover 
have,  on  the  average,  a  shorter  time  to  wait  for  their  first  concep- 
tion than  women  who  marry  before  the  age  of  20.  Women  who 
marry  after  the  age  of  25  have  to  wait  longer  after  marriage  for 
their  first  delivery ;  in  fact  the  older  the  woman  after  25,  the 
greater,  on  the  average,  the  interval  between  marriage  and  the 
first  delivery. 

Arranging  the  data  already  referred  to,  regarding  556  fruitful 
women,  in  relation  to  this  point  of  view,  it  appears  that  the  first 
birth  ensued: 


15 

Within 

months 

More 

10 

10  to  15 

to  2 

2  to  3 

than 

months 

months 

years 

years 

3  years 

of 

after 

after 

after 

after 

mar- 

mar- 

mar- 

mar- 

mar- 

riage. 

riage. 

riage. 

riage. 

riage. 

In  163  women  marrying  at 

ages  15  to  20  years  

•?6 

e-i 

46 

18 

10 

In  313  women  marrying  at 

o 

9w 

ages  20  to  25  years  

08 

1  1  -J 

S6 

7,2 

14 

In    70   women   marrying   at 

y 

3 

o  w 

O 

ages  25  to  33  years  

18 

•7Q 

12 

i 

In    10  women  marrying  at 

•J" 

ages  over  33  years  

•3 

I 

I 

i 

O 

To  give  percentages,  the  first  birth  occurred, 


15 

Within 

months 

More 

10 

10  to  15 

2  to 

2  to  3 

than 

months 

months 

years 

years 

3  years 

of 

after 

after 

after 

after 

mar- 

mar- 

mar- 

mar- ^ 

mar- 

riage. 

riage. 

riage. 

riage. 

riage. 

Women  marrying  at  ages  1  5 

to  20  years,  in  

22  .0% 

72.5% 

28.2% 

11.0% 

8.1% 

Women  marrying  at  ages  20 

'        /v 

O          J   /U 

/U 

to  2  5  years,  in  

71.7% 

7.6.  1% 

17   8% 

10.2% 

4-4% 

Women  marrying  at  ages  25 

o      o  /o 

O                 /  v 

*  /    "         /(/ 

to  33  years,  in  

2<;.7% 

42.8% 

17.1% 

12.8% 

1.4% 

Women    marrying    at    ages 

J       1    /€/ 

/           /v 

over  33  years,  in  

40.0% 

3.0  .O% 

10  .0% 

10.0% 

10.0% 

o          /i/ 

"  **   /€/ 

/€/ 

THE  SEXUAL  EPOCH  OF  THE  MENACME. 


369 


Thus  whereas  in  women  who  contracted  marriage  between  the 
ages  of  15  and  20  years,  only  54.5%  were  confined  for  the  first  time 
within  15  months  after  marriage,  in  women  who  contracted  mar- 
riage between  the  ages  of  20  and  25  years,  in  67.4%  the  first  de- 
livery occurred  within  15  months  of  marriage.  And  whereas  in 
those  who  married  at  the  earlier  age,  the  percentage  of  first  de- 
liveries occurring  between  15  months  and  2  years  after  marriage 
was  28.2,  in  those  who  married  between  the  ages  of  20  and  25, 
the  percentage  of  first  deliveries  after  the  stated  interval  was 
only  17.8. 

The  figures  compiled  by  Whitchead  and  Pfannkuch  give  similar 
results.  Of  700  women  who  married  between  the  ages  of  15  to 
20  years,  there  were  306  only  who  gave  birth  to  a  child  within  the 
first  two  years  after  marriage;  whereas  of  1,835  women  who  mar- 
ried between  the  ages  of  20  and  25  years,  no  less  than  1,661  gave 
birth  to  a  child  within  two  years  after  marriage  —  a  percentage 
of  43.7  in  the  former  case,  and  90.6  in  the  latter  case.  Pfannkuch, 
as  the  result  of  a  very  large  collection  of  figures  relating  to  this 
question,  found  that  in  women  marrying  before  the  age  of  20 
years,  the  average  number  of  months  before  the  first  delivery  was 
26;  whereas  in  women  marrying  after  the  age  of  20  years,  the 
average  number  of  months  before  the  first  delivery  was  20. 

According  to  Matthetvs  Duncan 


THERE  BECO 

ME  MOTHERS 

OF  EVERY  100  WOMEN  WHO  MARRY 

In  the 
ist  year  of 
married 
life. 

In  the 
2d  year  of 
married 
life. 

Between  the  ages  of  15  and  20  years  

n  .  71 

47  .  70 

Between  the  ages  of  20  and  25  years  

18.48 

QO  .  <;  i 

Between  the  ages  of  25  and  30  years  

12  .41 

7?.  80 

Between  the  ages  of  30  and  35  years  

1  1  .  44 

62  .  (H 

Between  the  ages  of  35  and  40  years  

9.  27 

4O  .  Q7 

Sadler  examined  the  relationship  between  the  age  at  which  mar- 
riage was  contracted  and  the  number  of  offspring  in  the  case  of 
the  wives  of  English  peers.  He  obtained  the  following  results: 

Age  at  marriage.  Births  per  marri.age 

12  to  1 6  years 4  •  40 

1 6  to  20  years 4-63 

20  to  24  years 5-21 

24  to  28  years 5-43 

24 


370 


THE  SEXUAL  LIFE  OF  WOMAN. 


From  exact  statistical  data  of  births  in  the  Scandinavian  coun- 
tries of  Europe  (Denmark,  Sweden  and  Norway),  Gochlert  com- 
piled the  following  table,  showing  the  percentages  of  fertility  at 
various  ages: 


•AGES. 

MARRIED  WOMEN. 

UNMARRIED  WOMEN. 

Den- 
mark. 

Swe- 
den. 

Nor- 
way. 

Den- 
mark. 

Swe- 
den. 

Nor- 
way. 

Under  20  years  

i  .0 

13-9 
26.5 
26.  7 

21  .O 

9-9 
i  .  i 

I  .0 
12.8 

24.7 

26.  1 

21.6 
12  .0 

1.8 

0.7 
u.  g 

24.7 

25-3 
21.3 
13.0 
3-i 

9.1 

43-9 
28.1 

n.  4 

\  5'4 
}  '•' 

7.0 

35-1 
27.9 
16.8 
9.0 

4.2 

4-9 
37-0 
32-4 
14.9 

7-i 

3-7 

From  20  to  25  years.  .  .  . 
From  25  to  30  years.  .  .  . 
From  30  to  35  years.  .  .  . 
From  35  to  40  years.  .  .  . 
From  40  to  45  years.  .  .  . 
Over  45  years  

From  this  table  it  appears  that  the  fertility  of  married  women 
increases  steadily  up  to  the  age  of  35  years,  but  after  this  age  it 
begins  to  decline.  What  a  marked  influence  the  age  at  marriage 
has  upon  fertility  is  shown  by  the  comparison  of  the  figures  relat- 
ing to  married  women  with  those  relating  to  unmarried  women; 
the  fertility  of  unmarried  mothers  attains  its  maximum  at  the 
ages  of  20  to  25  years.  In  the  countries  under  consideration  the 
average  age  of  women  at  the  time  of  marriage  is  25  to  27  years. 

In  order  to  obtain  a  still  clearer  picture  of  the  fertility  of 
women  in  relation  to  age,  Goehlert  has  combined  the  figures  relat- 
ing to  the  married  and  the  unmarried,  and  then  calculated  the 
percentages,  with  the  following  results : 


AGES. 


MARRIED  AND  UNMARRIED 
WOMEN. 


Denmark. 

Sweden. 

Norway. 

Under  20  years  

i   7 

1.6 

i  .  i 

From  20  to  25  years  :  . 

16  6 

I  e  .  I 

14  •  i 

From  25  to  30  years  

26.6 

2  <;  .0 

25  •  ^ 

From  30  to  35  years  

2S  •  1 

2  S  .  I 

24  .4 

From  3  5  to  40  years  

IQ  .  6 

20  .  4 

20  .O 

From  40  to  45  years  

0  -  2 

11.2 

12.2 

From  45  to  50  years  \ 

Over  50  years  J 

I  .0 

i  .6 

2.9 

THE  SEXUAL  EPOCH  OF  THE  MENACME.  371 

If,  finally,  we  combine  into  a  single  table  the  figures  relating  to 
all  three  of  these  countries,  we  obtain  the  following  results: 

Under  20  years I  •  5  % 

From  20  to  25  years IS-3% 

From  2  5  to  30  years 25.6% 

From  30  to  35  years 24.9% 

From  35  to  40  years 20.0% 

From  40  to  45  years 10.9% 

Over  45  years i .  8% 

From  these  figures  it  appears  that  the  maximum  fertility  of 
married  women  is  attained,  in  Denmark  at  the  age  of  31,  in  Nor- 
way at  the  age  of  31.7,  and  in  Sweden  at  the  age  of  32  years.  In 
the  case  of  unmarried  women,  the  maximum  fertility  is  at  the 
ages  of  24  to  26  years.  In  the  Austrian  Empire,  the  maximum 
fertility  of  women  is  attained  at  about  the  age  of  30  years;  in 
England  it  is  attained  between  the  ages  of  20  and  25  years. 

Divergent  results  as  regards  the  fertility  of  married  women  at 
different  ages  were  obtained  by  Goehlert  from  the  examination  of 
5,290  cases  from  the  reigning  families  of  Europe.  In  the  favourable 
position  as  regards  means  of  subsistence  occupied  by  the  members 
of  these  families,  marriage  naturally  occurs,  in  most  cases,  much 
earlier  in  life,  the  mean  age  at  marriage  being  between  19  and  22 
years  —  the  youngest  mother  (in  the  Capet  dynasty)  was  only 
13  years  of  age  —  and  for  this  reason  the  figures  relating  to  the 
younger  age-classes  are  larger  than  in  the  previous  tables.  But  as 
a  result  of  this,  the  reproductive  capacity  also  undergoes  an  earlier 
extinction,  so  that  of  these  women,  not  one  gave  birth  to  a  child 
when  she  was  over  50  years  of  age.  Goehlert  gives  the  following 
table,  compiled  from  these  5,290  instances: 

Under  20  years 8 .8% 

From  20  to  25  years 25  .4% 

From  25  to  30  years 29.4% 

From  30  to  35  years 21 .6% 

From  35  to  40  years 11.5% 

Over  40  years 3  .3% 

In  these  cases  the  maximum  fertility  was  obtained  at  the  age 
of  27. 

The  physiological  fertility  of  women  is  much  more  clearly  mani- 
fested when  we  compare  the  fertility  of  women  who  have  been 
married  a  few  years  only,  with  the  fertility  of  women  in  the 
later  years  of  married  life.  In  the  earlier  period,  the  effective 
fertility  more  nearly  approaches  the  physiological  fertility,  because 
at  this  time  the  various  influences  by  means  of  which  fertility  is 


372 


THE  SEXUAL  LIFE  OF  WOMAN. 


later  so  greatly  diminished  have  not  yet  come  into  operation.  In 
this  connection  the  following  data,  published  by  Korosi,  regarding 
the  percentage  fertility  of  recently  married  women,  and  that  of 
married  wromen  in  general,  will  be  found  of  interest: 


Recently- 
married 

All 
married 

• 

women. 

women. 

At  ages  20  to  35 

years  

•?2     Q% 

20    6% 

At  ages  35  to  40 

years  

32  .  7% 

14    7% 

At  ages  40  to  45 

years  

21  .4.% 

C      Q% 

Inasmuch  as  we  learn  from  this  table  that  in  the  case  of  women 
aged  40  and  upward,  the  newly-married  exhibit  a  fertility  of  four 
times  as  great  as  that  of  married  women  in  general,  in  whom 
pregnancy  has  already  become  rare,  we  can  infer  the  influence 
upon  fertility  of  abstinence  and  of  artificial  measures  for  the  pre- 
vention of  conception. 

On  the  average,  the  maximum  fertility  of  woman,  that  is,  the 
maximum  of  effective  fertility,  is  attained  at  the  age  of  18  to  20 
years.  Extreme  youth  fulness,  and  also  the  opposite  condition, 
too  advanced  an  age,  when  marriage  is  entered  on,  impair  a  wo- 
man's fertility :  whereas  the  conditions  most  favourable  to  fertility 
are  that,  at  the  time  of  marriage,  the  uterus  should  have  attained 
its  fullest  development,  and  the  ovaries  also  should  be  completely 
mature ;  this  is  not  usually  the  case  at  puberty,  but  rather  at  the 
age  of  20,  21,  or  22  years.  In  Austria-Hungary,  of  100  marriages 
in  which  the  wife's  age  at  marriage  was  less  than  18  years,  the 
average  offspring  in  the  course  of  a  single  year  were  36  to  38 
children ;  in  the  case  of  100  marriages  in  which  the  wife's  age  at 
marriage  was  18  to  20  years,  the  average  offspring  in  a  year  were 
40;  this  being  the  maximum  fertility,  the  number  of  offspring  in  a 
year  per  hundred  marriages  (i.  e.,  the  percentage  fertility),  now 
undergoes  a  regular  decline  as  the  wife's  age  at  marriage  increases ; 
at  an  age  of  25,  the  percentage  fertility  is  32 ;  at  the  age  of  30 
years,  the  fertility  is  24%  ;  at  the  age  of  35,  17%  ;  at  the  age  of 
40  years  barely  10%  ;  at  the  age  of  45,  7%  ;  at  ages  45  to  50, 
0.1%.  Thus,  from  the  last  figure,  we  see  that  of  a  thousand  women 
marrying  at  the  age  of  50  years,  one  only  gives  birth  to  a  child. 


THE  SEXUAL  EPOCH  OF  THE  MENACME. 


373 


Men  obtain  their  maximum  fertility  (i.  e.,  procreative  capacity) 
at  the  age  of  25  or  26  years ;  at  this  age  their  fertility  amounts  to 
35%  (that  is,  of  100  marriages  at  this  age,  35  children  will  on  the 
average  be  born  within  a  single  year)  ;  at  the  age  of  35  years,  the 
percentage  fertility  of  men  falls  to  23 ;  at  the  age  of  45  years,  it  is 
9l/2°/°  ;  at  55,  2.2%  ;  at  65,  l/2%  (Korosi-Blaschko). 

Whereas  hitherto  we  have  considered  only  the  monogenous  fer- 
tility of  married  women,  we  must  remember  that  the  figures  relat- 
ing to  their  biogenous  fertility  are  also  of  interest  —  that  is  to  say, 
the  changes  which  a  woman's  fertility  experiences  in  married  life 
in  respect  of  the.  peculiarities  of  her  husband;  and  of  these  pecu- 
liarities, the  easiest  to  make  the  object  of  statistical  investigation  is 
the  husband's  age.  The  age  of  the  husband  exercises  an  important 
influence  upon  the  fertility  of  the  wife,  as  is  proved  by  the  follow- 
ing figures  published  by  Korosi: 


25  to  30  years . 
30  to  35  years. 
35  to  40  years . 
40  to  45  years. 
45  to  50  years, 
50  to  55  years. 


OF  THE  FATHER. 

AGE  OF  THE  MOTHER. 

25  years. 

30  years. 

35  years' 

35-6% 
31-2% 
27-5% 

25-0% 
23-6% 
21.8% 
16.7% 
14-4% 

21.2% 
19-9% 
19-4% 
14-0% 
10-9% 
I0.9% 

Also: 


AGE  OF  THE  MOTHER. 


AGE  OF  THE  FATHER. 


25  years. 

35  years. 

45  years. 

55  years. 

Under  20  years  

40     1% 

20  to  25  years   

43    0% 

TI    3% 

16  o% 

25  to  30  years  

20   8% 

27     T% 

18   <;% 

30  to  3  c  years.  . 

23.5% 

27  .  7% 

14.4% 

8.1% 

35  to  40  years  

18.9% 

n.8% 

6.7% 

40  to  45  years  

6.6% 

6.1% 

3.0% 

We  learn  from  these  figures  that  the  maximum  fertility  is  ex- 
hibited by  a  woman  18  years  of  age,  when  married  to  a  man  25 
years  of  age;  less  fertile  is  a  woman  25  to  30  years  of  age  married 
to  a  man  28  years  of  age;  still  less  fertile  is  a  woman  35  years  of 
age  married  to  a  man  29  years  of  age.  Neither  the  age  of  the 


374  THE  SEXUAL  LIFE  OF  WOMAN. 

mother  alone,  nor  that  of  the  father  alone,  is  determinative  of  the 
fertility  of  the  marriage,  for  the  fertility  of  young  wives  married 
to  elderly  husbands  is  quite  different  from  that  of  young  wives 
married  to  young  husbands.  Very  various  age-combinations  are 
possible,  and  each  exhibits  an  average  fertility  peculiar  to  itself. 

We  can  also  regard  the  question  from  the  standpoint  of  the 
difference  between  the  ages  of  husband  and  wife  respectively.  In 
this  connection,  Korosi  is  led  by  his  tables  to  the  conclusion  that 
wives  between  the  ages  of  18  and  20  years  attain  their  maximum 
fertility  when  married  to  men  7  years  older  than  themselves ;  women 
of  25  years  when  married  to  men  3  years  older  than  themselves; 
women  of  29  years  when  married  to  men  of  the  same  age ;  women 
of  30  years  and  upward  attain  their  maximum  fertility  only  when 
married  to  men  younger  than  themselves.  Men,  on  the  contrary, 
always  attain  their  maximum  fertility  when  married  to  women 
younger  than  themselves.  The  age  of  maximum  fertility  differs 
in  the  two  sexes,  and  those  marriages  will  be  most  fruitful  in  which 
husband  and  wife  are  each  of  the  age  most  favorable  to  fertility. 
This  will  be  the  case  when  the  age  of  the  wife  is  18  to  20  years, 
and  that  of  the  husband  24  to  26  or  perhaps  29  years. 

In  connection  with  the  question  of  fertility,  we  have  also  to  take 
into  consideration  the  vitality  of  the  children  born,  that  is,  what 
proportion  of  those  born  survive.  According  to  Korosi' s  interest- 
ing papers  regarding  the  fertility  of  the  inhabitants  of  Buda- 
Pesth,  we  learn  that  for  every  100  marriages  which  have  persisted 
for  thirty  years  and  upward,  there  were  born,  on  the  average,  539 
children,  of  whom  during  this  period  241  died,  so  that  the  per- 
centage of  survivals  was  55.28.  Parents  who  have  lost  one  only 
of  several  children  must,  therefore  regard  themselves  as  excep- 
tionally favoured  by  fortune. 

Social  position,  occupation,  and  religion,  have,  according  to  the 
last-quoted  author,  a  notable  influence  on  fertility.  His  investiga- 
tions showed  that  the  Roman  Catholics  and  the  Jews  exhibited  the 
greatest  fertility ;  among  the  Catholics  there  were  541  children, 
and  among  the  Jews  557  children,  per  loo  marriages.  Amongst 
loo  Protestant  families,  on  the  other  hand,  only  479  children  had 
been  born.  It  will  be  seen  that  the  theory  of  the  comparatively 
enormous  fertility  of  the  Jewish  race  is  not  supported  by  these 
statistics.  The  Jews  do,  however,  exhibit  a  greater  power  of  rear- 
ing children,  for  among  them  the  marriages  of  more  than  30 
years'  duration  had  6i^i%  of  the  children  still  living;  among  the 
Protestants  57^4%  survived;  and  among  the  Catholics  only 


THE  SEXUAL  EPOCH  OF  THE  MENACME.  375 

It  thus  appears  that  the  surviving  offspring  per  100  marriages  of  30 
years'  duration  were,  among  the  Catholics  278,  among  the  Protest- 
ants 252,  and  among  the  Jews  349. 

The  question  whether,  and  to  what  extent,  the  age  of  the  parents 
has  an  influence  on  the  vitality  of  the  children,  is  answered  by 
Korosi's  mortality  statistics  in  the  sense  that  mothers  below  20 
years  of  age  give  birth  to  a  larger  proportion  of  children  deficient 
in  vital  power.  Where  the  mothers  had  married  at  the  age  of  16, 
the  mortality  of  their  offspring  was,  among  Catholics  43%,  among 
Jews  33%  ;  married  at  17,  Catholic  mortality  44%,  Jewish 
30%  ;  married  at  18,  Catholic  mortality  42%,  Jewish  32%  ;  married 
at  19,  Catholic  mortality  41%,  Jewish  29%  ;  married  at  20,  Catholic 
mortality  40%,  Jewish  26%.  Of  the  children  whose  fathers  had 
married  at  the  age  of  24,  32%  had  died;  of  those  whose  fathers  had 
married  at  23,  37%  had  died;  of  those  whose  fathers  had  married 
at  20,  42%  had  died;  and  of  those  whose  fathers  had  married  be- 
fore 20,  actually  44%  had  died.  It  thus  appears  that  the  children 
alike  of  very  young  mothers  and  of  very  young  fathers  have  a 
lessened  chance  of  survival. 

Inasmuch  as  the  fertility  of  the  wife  is  a  product  of  two  factors, 
her  own  peculiar  fertility,  and  that  of  the  procreating  male,  the 
question  of  the  fertility  of  women  cannot  be  accurately  treated  in- 
dependently of  this  second  consideration;  hereby,  however,  is  intro- 
duced a  multiplicity  of  obscure  combinations,  by  which  the  value  of 
all  the  statistical  data  of  fertility  in  women  is  seriously  impaired. 

These  data  give  as  the  measure  of  fertility,  the  number  of  chil- 
dren per  marriage  actually  brought  up,  embracing  fruitful  mar- 
riages, sterile  marriages,  and  those  not  yet  fruitful.  In  Berlin,  in 
Copenhagen,  and  in  Buda-Pesth,  the  average  thus  attained  was 
slightly  less  than  three  births  to  each  family,  whilst  the  number 
of  children  actually  living  averaged  two  per  family.  A  more  ac- 
curate representation  of  fertility  is  obtained  by  ascertaining  the 
number  of  children  born,  and  the  number  of  children  living  in 
relation  to  the  duration  of  marriages  reckoned  in  years,  that  is 
beginning  with  marriages  of  one  year's  duration,  and  proceeding 
year  by  year  to  the  highest  recorded  duration  of  marriage.  In 
this  way  interesting  statistics  have  been  obtained;  for  example,  one 
who  has  completed  thirty  years  of  married  life  may  count  on  the 
average  that  five  or  six  children  will  have  been  born  to  him,  but 
-may  also  reckon  on  having  buried  two  or  three  at  least  of  these. 
(Korosi.*) 


376  THE  SEXUAL  LIFE  OF  WOMAN. 

Fertility  is,  as  many  facts  indicate,  also  dependent  on  nutrition. 
A  distinct  proof,  says  Spencer,  writing  on  the  "  Coincidence  be- 
tween high  Nutrition  and  Genesis,"  that  abundant  nutriment  in- 
creases the  number  of  births,  and  vice  versa,  is  found  among  the 
mammalia;  compare,  for  instance,  the  litter  of  the  dog  with  that 
of  the  wolf  and  the  fox.  Whilst  the  dog's  litter  numbers  6  to  14, 
that  of  the  wolf  numbers  5  to  7,  that  of  the  fox  4  to  6.  The 
wild  cat  gives  birth  to  4  or  5  kittens  once  a  year,  the  domesticated 
cat  to  5  or  6,  twice  or  thrice  annually.  The  most  remarkable  con- 
trast, in  this  respect,  exists  between  the  wild  and  the  domesticated 
breeds  of  swine.  The  wild  sow  gives  birth  once  a  year  to  a  litter 
of  4,  8,  or  10  pigs  (the  number  increasing  in  successive  litters)  ;  the 
domesticated  sow  has  often  as  many  as  17  in  a  single  litter,  whilst 
in  two  years  five  litters,  each  numbering  10  pigs,  are  commonly 
born. 

Darwin  also  draws  attention  to  the  fact  that  animals  under 
domestication,  being  fed  more  abundantly  and  regularly  than  their 
wild  allies,  procreate  at  shorter  intervals  and  are  markedly  more 
fertile  than  the  latter.  He  states  that  the  wild  rabbit  has  four 
litters  annually,  each  numbering  4  to  8  young;  whereas  the  tame 
rabbit  reproduces  its  kind  six  to  seven  times  annually,  and  gives 
birth  to  litters  numbering  4  to  n.  Among  birds,  analogous  phe- 
nomena are  observed.  The  wild  duck,  for  instance,  lays  5  to  10 
eggs  in  the  course  of  the  year,  whereas  the  tame  duck  lays  from 
80  to  100;  the  wild  grey  goose  lays  5  to  8  eggs,  the  domesticated 
goose  13  to  1 8. 

It  must  be  added  that  this  exceptional  fertility  is  manifested  in 
animals  that  are  quite  inactive  in  comparison  with  their  wild  allies ; 
not  only  are  they  richly  fed,  but  they  get  their  food  without  work- 
ing for  it.  Moreover,  it  is  easy  to  observe  that  among  the  domes- 
ticated mammals  the  well-fed  are  more  fertile  than  the  ill-fed. 

That  in  the  human  species  also,  fertility  is  influenced  to  a  notable 
degree  by  nutritive  conditions,  is  shown  by  statistical  investigation. 
After  years  distinguished  by  an  exceptionally  good  harvest  the 
number  of  children  born  is  considerably  greater  than  in  normal 
conditions;  whereas  after  a  famine  the  opposite  is  observed. 
Malthus's  law  of  population  states,  inter  alia,  that  the  population 
increases  when  the  amount  of  available  nutriment  increases,  that 
is,  that  favourable  nutritive  conditions  cause  an  increase,  that  un- 
favourable nutritive  conditions  cause  a  decrease,  of  population. 
Hardships  and  exhausting  occupations  diminish  the  fertility  of 
women.  The  remarkable  fertility  of  the  Kaffirs  is  referred  to  the 


THE  SEXUAL  EPOCH  OF  THE  MENACME.  377 

fact  that  this  people,  possessing  large  herds  of  cattle,  lead  a  life 
comparatively  free  from  care ;  it  is  no  less  true  that  the  Boer 
women,  who  lead  a  life  of  well-fed  leisure,  have  very  large  fami- 
lies; whereas  the  Hottentot  women,  poor,  ill-nourished,  and  hard 
working,  seldom  bear  more  than  three  children. 

Generally  speaking,  it  may  be  said  that  fertility  of  the  soil,  in 
connection  with  an  easily  gained  livelihood,  favours  also  human 
fertility,  notwithstanding  the  fact  that  certain  statistical  data  seem 
to  conflict  with  this  proposition.  Sadler,  for  instance,  concludes  that 
an  increase  in  the  price  of  the  necessaries  of  life  does  not  per  se 
check  fertility,  but,  indeed,  rather  increases  it ;  he  considers  that 
the  apparent  decline  in  fertility  is  due  to  the  fact  that  the  number 
of  marriages  diminishes,  owing  to  the  rise  in  prices.  We  must, 
however,  point  out,  that  an  increase  in  price  of  the  necessaries  of 
life  is  often  associated  with  a  rise  in  wages,  and  is  therefore  not 
necessarily  identified  with  deficient  nutrition ;  when,  however,  such 
a  rise  in  prices  leads  to  actual  want,  a  limitation  of  fertility  will 
certainly  result ;  this  has  been  proved  by  Legoyt  and  Filler  me  with 
regard  to  failure  of  the  crops.  Famine  and  disease  lower  the 
number  of  births ;  a  less  severe  deficiency  of  nutriment  often  lowers 
only  the  quality  of  those  born.  Mai  thus  was  of  opinion  that  the 
population  of  a  country  at  any  time  was  related  to  the  quantity  of 
nutriment  produced  or  imported  therein,  on  the  one  hand,  and, 
on  the  other,  to  the  liberality  with  which  this  nutriment  was  dis- 
tributed to*  the  individual.  In  countries  where  corn  forms  the 
principal  crop,  we  find  a  thicker  population  than  in  pasture  lands; 
and  where  rice  is  the  principal  crop,  the  population  is  even  more 
abundant  than  it  is  in  corn  growing  countries. 

Passing  to  the  consideration  of  the  individual  nutritive  elements, 
we  find  that  these  also  influence  fertility.  Above  all,  it  has  been 
proved  that  alcohol  notably  diminishes  the  fertility  of  women. 
Lip  pick  states  that  of  100  women  in  Karnten  and  Krain  suffering 
from  chronic  alcoholism,  28.3  were  barren.  In  England,  where  the 
abuse  of  alcoholic  beverages  is  also  very  frequently  observed  in 
women,  the  same  phenomenon  has  been  noted.  Matthews  Duncan 
held  that  alcohol  exercised  a  specific  deleterious  influence  on  fer- 
tility. Moreover,  in  addition  to  the  constitutional  disturbances  pro- 
duced by  the  abuse  of  alcohol,  this  beverage  also  exercises  a  well- 
known  pathpgenetic  influence  upon  the  female  reproductive  or- 
gans ;  with  especial  frequency,  chronic  oophoritis  may  be  shown  to 
depend  on  this  exciting  cause. 


378  THE  SEXUAL  LIFE  OF  WOMAN. 

A  diet  consisting  mainly  of  fish  is  known  to  increase  the  sexual 
impulse,  and  is  said  also  to  increase  fertility.  Further,  a  diet  con- 
sisting mainly  of  potatoes  or  rice  is  said  to  favour  reproduction; 
compare,  for  instance,  the  fertility  of  the  Hindoos,  who  abstain 
entirely  from  animal  fcod,  and  of  the  Qiinese,  who  live  chiefly  on 
rice.  Davy  maintained  that  the  women  of  races  living  chiefly  on 
fish  were  handsomer  and  more  fertile  than  others:  and  Mon- 
tesquieu suggested  that  there  was  an  association  between  the  abun- 
dant population  of  sea-ports  and  also  of  Japan  and  China,  and  the 
large  quantity  of  fish  consumed  in  those  places.  On  the  other 
hand,  a  diet  consisting  chiefly  of  meat  is  said  to  have  an  unfavour- 
able influence  in  this  direction;  in  support  of  this  view  it  is  pointed 
out  that  races  living  by  the  chase,  and  living  therefore  almost  en- 
tirely on  meat,  have  very  small  families.  This  generalization  is 
invalidated  by  the  fact  that  Englishwomen,  who  eat  far  more 
meat  than  the  women  of  the  Latin  races,  are  nevertheless  dis- 
tinguished by  their  great  fertility. 

In  his  "  History  of  Civilisation  in  England  "  Buckle  writes:  "The 
population  of  a  country,  although  influenced  by  many  other  con- 
ditions, unquestionably  rises  and  falls  in  proportion  as  the  supply 
of  nutriment  is  abundant  or  the  reverse."  Herbert  Spencer  also 
states  that  "  every  increment  in  the  supply  of  nutriment  is  followed 
by  an  increment  in  fertility." 

It  must  not  be  forgotten  that,  in  addition  to  the  more  or  less 
abundant  supply  of  nutriment,  there  are  always  other  influences 
affecting  fertility;  the  general  mode  of  life,  race,  climatic  condi- 
tions, etc.,  may,  in  various  ways,  co-operate  with  or  countervail  the 
influence  of  nutritive  conditions.  If,  with  the  best  possible  supply 
of  nutriment,  there  is  associated  a  luxurious  and  enervating  mode 
of  life,  the  abuse  of  alcohol,  severe  intellectual  exertion,  or  sexual 
excesses,  the  general  result  will  be  a  diminution  in  fertility.  And 
it  is  easy  to  understand  why  Cros,  although  perhaps  with  little  jus- 
tification, goes  so  far  as  to  regard  easy  circumstances  as  an  active 
cause  of  depopulation.  "  It  is  the  poor,"  he  writes,  "  and  the  less 
wealthy  departments  of  France,  in  which  we  find  the  most  chil- 
dren." In  estimating  fertility,  however,  we  must  never  fail  to  take 
into  consideration  the  more  extensive  employment  of  means  for  the 
prevention  of  pregnancy  among  the  upper  classes  of  society. 

To  a  certain  extent  we  can  trace  the  influence  of  climate  and  of 
season  upon  fertility.  Heat  appears  to  favour  fertility;  Haycraft's 
figures  for  the  eight  largest  towns  of  Scotland  show  clearly  how 
the  number  of  conceptions  rises  and  falls  par  I  passu  with  the  tem- 


THE  SEXUAL  EPOCH  OF  THE  MENACME.  379 

perature.  Lower  animals  also,  when  brought  from  a  colder  to  a 
warmer  neighbourhood,  exhibit  an  earlier  and  more  frequently 
recurring  "  heat."  In  Europe,  however,  the  Northern  races  appear 
more  fertile  than  those  of  the  south. 

Of  the  seasons,  spring  is  the  one  especially  favourable  to 
fertility.  Quetelet,  who  proves  by  numerous  statistical  data  that 
the  maximum  of  conceptions  occurs  in  May,  attributes  this  fact  to 
a  general  increase  in  the  vital  forces  occurring  in  spring,  after  the 
cold  of  winter.  Villerme,  however,  goes  back  to  the  older  expla- 
nation, that  the  increase  in  the  number  of  conceptions  in  May  and 
June  is  due  to  social  and  economic  conditions.  The  return  of 
spring,  especially  the  end  of  spring  and  the  beginning  of  summer, 
a  time  of  year  in  which  the  means  of  subsistence  are  provided  in 
exceptional  quantity,  and  of  especially  good  quality,  the  season  also 
of  festivals  and  social  reunion,  when  the  two  sexes  are  brought 
into  more  intimate  contact  and  when  the  majority  of  marriages 
occur — these  are  the  conditions  associated  with  the  season  of 
greatest  fertility.  The  figures  of  Wappaeus  also  confirm  the  in- 
fluence of  spring  in  favouring  fertility.  He  found,  however,  that 
there  were  two  seasons  of  maximal  fertility.  The  first  at  the  end 
of  spring  and  the  beginning  of  summer;  the  second  in  winter, 
especially  in  December.  Mid-winter  is  for  most  people  a  period 
of  domestic  amusement  and  relaxation,  one  of  exceptionally  good 
nutrition,  and  of  social  reunion;  the  spring  increase  in  fertility  is 
a  part  of  the  awakening  and  increase  of  the  reproductive  forces 
of  nature  at  large,  which  recurs  every  spring-time. 

Every  marked  and  sudden  change  in  the  mode  of  life  has  an 
unfavourable  influence  on  fertility.  Darwin  reports  that  mares  who 
have  for  some  time  been  stall-fed  with  dry  fodder  and  are  then 
put  out  to  grass  are  at  first  infertile  after  the  change.  Europeans 
going  to  reside  in  the  tropics  experience  a  notable  decline  in  fer- 
tility as  a  result  of  the  change  of  climate.  According  to  Virchow, 
the  fertility  of  European  women  who  become  acclimatized  in  the 
tropics  declines  very  gradually,  but  in  the  course  of  a  few  genera- 
tions is  almost  completely  annulled. 

The  marriage  of  near  kin  is  believed  also  to  diminish  fertility. 
As  regards  in-breeding  in  the  lower  animals,  it  is  well  known  that 
when  nearly  related  animals  copulate,  the  number  of  the  offspring 
is  below  the  average.  Natlntsius  paired  a  sow  with  its  own  uncle, 
the  boar  having  proved  productive  in  intercourse  with  other  sows ; 
the  litter  numbered  five  to  six  only.  This  sow,  which  belonged  to 
the  great  Yorkshire  race,  was  then  paired  with  a  small  black  boar, 


380  THE  SEXUAL  LIFE  OF  WOMAN. 

which  in  intercourse  with  sows  of  its  own  variety  had  procreated 
litters  numbering  six  or  seven;  as  a  result  of  her  first  pairing  \vith 
the  black  boar,  the  sow  cast  a  litter  numbering  twenty-one  whilst 
the  second  attempt  produced  a  litter  of  eighteen.  Similar  results 
were  obtained  by  Crampc,  in  his  experiments  in  the  inbreeding  of 
rats. 

Some  authorities  declare  that  the  results  of  in-breeding  are  simi- 
lar in  the  'human  species,  that  the  marriages  of  near  kin  are  less 
fruitful  than  the  average.  Darwin  writes  in  this  connection: 
"  With  regard  to  human  beings,  the  question  whether  breeding 
in-and-in  is  also  deleterious,  will  probably  never  receive  a  direct 
answer,  for  man  reproduces  his  kind  so  very  slowly,  and  cannot  be 
made  the  object  of  experiment.  The  very  general  disinclination 
of  nearly  all  races  to  the  marriage  of  near  kin,  which  has  existed 
from  the  very  earliest  times,  is  of  weight  in  relation  to  this  ques- 
tion. Indeed  we  appear  almost  justified  in  applying  to  the  human 
race  the  experience  gained  by  experiment  on  the  higher  mammals." 

Darwin's  assumption  regarding  the  effect  upon  fertility  of  the 
marriage  of  near  kin  in  the  human  species,  cannot,  however,  be 
accepted  without  qualification.  In  ancient  times  there  was  no  uni- 
formity of  opinion  on  this  topic.  It  is  well  known  that  among 
the  Phoenicians,  a  son  might  marry  his  mother,  and  a  father  his 
daughter;  and  among  the  ancient  Arabs  it  was  the  legal  duty  of 
the  son  to  marry  his  widowed  mother.  Moses,  on  the  contrary, 
forbade  marriages  between  parents  and  children,  between  brothers 
and  sisters,  also  marriage  with  a  father's  sister,  with  a  wife's  mother, 
and  with  an  uncle's  widow. 

Darwin  considered  that  the  marriage  of  first  cousins  was  not  un- 
favourable to  fertility.  Of  97  such  marriages,  14  were  sterile, 
whilst  of  217  marriages  of  those  not  akin,  35  were  sterile;  the  per- 
centage in  both  cases  being  almost  identical.  Maiitcgazza,  who  re- 
gards kinship  in  marriage  as  unfavourable  to  fertility,  found  never- 
theless that  among  512  marriages  of  near  kin,  only  8  to  9^  were 
sterile.  It  is  widely  believed  that  the  dying  out  of  many  aristo- 
cratic families  is  dependent  on  the  in-breeding-  .so  common  in  this 
class  —  but  it  must  be  admitted  that  scientific  evidence  in  support 
of  this  belief  is  lacking.  Incest  in  the  human  species  may  certainly 
result  in  fertilization.  Among  the  Jews,  marriages  of  near  kin  are 
very  common,  and  often  prove  extremely  fruitful. 

Gohlert  made  a  statistical  investigation  of  the  fertility  of  the 
reigning  families  of  Europe,  in  order  to  throw  light  on  this  question. 
In  the  Capet  dynasty,  118  marriages  of  near  kin  took  place,  and  of 


THE  SEXUAL  EPOCH  OF  THE  MENACME.  381 

these  41  were  sterile;  in  the  Wettin  dynasty  (Saxony),  there  were 
28  such  marriages,  of  which  7  were  sterile,  and  i  produced  one 
child  only  ;  in  the  Wittelsbach  dynasty  (Bavaria),  29  such  marriages, 
of  which  9  were  sterile,  and  3  produced  only  one  child  each.  Thus 
of  175  marriages  of  near  kin,  57,  or  32.6^  remained  sterile.  Fur- 
ther, in  the  Habsburg-Lothringen  dynasty,  of  no  marriages,  25 
were  marriages  of  near  kin,  and  of  these  33$  remained  sterile. 

It  has  been  assumed  since  the  days  of  antiquity  that  temperament 
and  constitution  exercise  some  influence  on  fertility.  Hippocrates, 
Soranus,  and  Diokles,  are  among  the  ancient  authors  who  refer  to 
this  matter.  Soranus  says  very  justly:  "  Since  most  marriages  are 
contracted,  not  from  love,  but  for  the  procreation  of  children,  it 
is  irrational,  when  choosing  a  wife,  to  have  regard,  not  to  her  prob- 
able fruit  fulness,  but  instead  of  this  to  the  social  position  and  the 
wealth  of  her  parents." 

It  would  appear  that  a  certain  dissimilarity  in  physical  consti- 
tution and  temperament  between  husband  and  wife  is  favourable 
to  the  fertility  of  the  marriage.  For  instance,  a  vivacious,  dark 
husband,  and  a  lethargic,  fair  wife,  are  better  suited  to  one  another 
than  a  husband  and  wife  both  extremely  active,  or  both  of  ex- 
tremely phlegmatic  temperament. 

Toussaint  Loua  published  the  following  figures  regarding  the 
fertility  of  the  women  of  the  various  countries  of  Europe: 


COUNTRY. 

Number  of 
births  per 
hundred 
inhabitants. 

FERTILITY  OF  WOMEN  BETWEEN 
THE  AGES  OF  15  AND  45  YEARS.  ] 

Married. 

Unmarried. 

Average. 

Hungary    

4-94 
4.12 

3-93 
3-77 
3-67 
3-6? 
3-63 
3.58 
3-53 
3-25 
3.12 
3.12 
3.10 
3-°5 
3-°4 

2  .96 
2  .69 
2.63 

17.8 
20.5 
16  .4 
17.7 
16.1 
16  .  o 
15.8 

15-5 
15.8 
14.8 
14-4 
13-5 
14  .0 

13-7 
i3-i 
13.2 
12.3 
ii.  6 

Russia        .                 

Austria       .             ... 

Germany  

34-8 
28.8 
35-3 

2-9 

2.4 

I  .0 

Italy         

Holland      

England    

29.7 
32.8 

33-7 
28.5 

1.6 

2-5 

1.8 

2.8 

Scotland    

Belgium          .    

Denmark            

Norway    

29-3 
29  .  i 
29.7 

2  .  2 

2-5 
I  .  I 

Sweden              

Switzerland            

Ireland  

29.8 
20.3 

o-5 
1.8 

France  

382  THE  SEXUAL  LIFE  OF  WOMAN. 

In  towns,  conjugal  fertility  is  less,  extra-conjugal  fertility  greater, 
than  in  the  country.  An  increase  in  factory-labour  gives  rise  to  an 
increase  in  the  population,  but  to  a  decline  in  the  vitality  of  the 
offspring;  that  is  to  say,  it  causes  a  quantitative  increase,  and  a 
qualitative  decrease,  in  fertility.  An  increase  in  agricultural  labour 
has  precisely  the  opposite  effect.  The  influence  of  war  upon  fer- 
tility is  unfavourable  both  quantitatively,  and  qualitatively.  Accord- 
ing to  Tschouriloff,  the  introduction  of  universal  military  service, 
by  withdrawing  for  a  time  all  the  most  vigorous  men  from  domestic 
life,  tends  to  diminish  fertility.  Extensive  emigration  from  a 
country  in  which  the  soil  is  fertile,  and  where  the  vital  conditions 
are  generally  favourable,  is  stated  by  Bertillon  to  cause  an  increased 
fertility  in  the  mother  country;  he  further  states  that  an  increase 
in  the  number  of  the  proprietors  of  the  soil  is  followed  by  dimin- 
ished fertility,  and  vice  versa. 

Prostitutes  show  as  a  rule  a  very  low  fertility.  According  to 
the  data  of  Tarnowskaja,  the  fertility  of  prostitutes  in  Russia  is 
34$,  whilst  married  women  of  similar  ages  in  Russia  exhibit  a  fer- 
tility of  51.8$.  Gurrieri  found  60$  of  prostitutes  childless. 

The  fertility  of  female  criminals  was  found  by  Lombroso  to  be 
undiminished.  On  the  average,  poisoners  had  given  birth  to  4.5 
children,  other  murderesses  to  3.2  children,  child-murderesses  to  2 
children ;  thus  the  prisoners  whose  crime  is  commonly  dependent 
on  an  abnormal  eroticism  had  a  fertility  above  the  average. 

The  diminished  fertility  of  prostitutes  depends  in  part  upon  fre- 
quent venereal  infection,  in  part  upon  the  unfavourable  influence 
of  the  mercury  and  iodide  of  potassium  administered  for  the  cure 
of  such  infection,  also  upon  the  frequency  with  which  they  con- 
sume excessive  quantities  of  alcohol,  upon  the  excessive  frequency 
of  coitus,  which  exercises  a  traumatic  influence,  upon  the  irregular 
mode  of  life,  and  upon  their  disinclination  to  be  burdened  with 
children. 

Conjugal  fertility,  that  is  to  say,  the  ratio  between  legitimate 
births  and  the  number  of  married  women  between  the  ages  of 
15  and  50  years,  has  declined  in  Germany  during  the  last  decades. 
It  was : 

During  the  years  1872  to  1875 29 .  7% 

During  the  years  1879  to  1882 27.4% 

During  the  years  x88o  to  ^892 26.5% 


THE  SEXUAL  EPOCH  OF  THE  MENACME.  383 

This  decline  is  small,  but  it  is  much  more  manifest  in  urban 
than  in  rural  districts.  This  fact  is  shown  by  the  following  figures, 
relating  to  fertility  in  Prussia: 

1872  to  1879.  1894  to  1897. 

In  all  towns 26.9  24.0 

In  Berlin 23.8  16.9 

In  other  large  towns 26.7  23.5 

In  rural  districts 28.8  29.0 

This  difference  depends  principally  on  the  fact  that  in  the  large 
towns  of  Germany  (and  still  more  in  those  of  France)  the  use  of 
means  for  the  prevention  of  pregnancy  is  continually  increasing, 
whereas  the  population  of  the  rural  districts  is  as  yet  less  familiar 
with  the  use  of  these  measures. 

According  to  Hellstenius,  conjugal  fertility,  that  is,  the  number 
of  children  per  married  couple,  is  as  follows : 

In  the  Netherlands 4 . 88 

Norway 4.70 

Prussia 4 . 60 

Bavaria 4-55 

Sweden 4-52 

Saxony 4-35 

England 4-33 

Belgium 4-23 

Denmark 4.18 

France 3 . 46 

Tallquist,  who  has  published  a  statistical  investigation  concerning 
the  modern  tendency  to  diminished  fertility,  arrives  at  lower  figures 
than  Hellstenius.  According  to  him,  conjugal  fertility  is: 

In  Prussia 4-n 

England 4.10 

Belgium 4.12 

France 2.09 

In  various  States  of  the  American  Union 2  . 5  to  3  .o 

From  the  Almanach  de  Gotha  I7 acker  obtained  figures  showing 
that  each  family  of  the  higher  aristocracy  has  on  the  average  the 
following  number  of  children. 

In  France 2.0 

Italy 3.0 

Germany '.  .  .  4.8 

England 4.9 

Russia 5.1 

According  to  the  figures  we  have  published,  the  fertility  of  women 
suffices  for  the  production  during  the  sexual  life  of  a  small  number 


384  THE  SEXUAL  LIFE  OF  WOMAN. 

only  of  children,  averaging,  in  fact,  4  to  5  children  per  marriage. 
Many  mothers,  however,  give  birth  to  a  very  large  number  of  chil- 
dren. Among  73,000  families  inhabiting  Buda-Pesth,  Korosi  found 
300  mothers  who  had  had  15  children  or  more;  7  mothers  who  had 
each  had  21  children;  and  3  mothers  who  had  given  birth  respec- 
tively to  22,  23  and  24  children. 

A  newspaper  report  states  that  the  wife  of  a  citizen  of  Buda- 
Pesth,  during  the  43  years  of  her  married  life,  gave  birth  to  32 
children.  In  the  year  1902,  a  Bohemian  woman  gave  birth  to  her 
twenty-fourth  child.  Stieda  reports  the  cases  of  two  mothers,  one 
of  whom  had  21,  and  the  other  23  children.  The  wife  of  the  Ger- 
man Emperor,  Albrecht  I,  and  the  wife  of  Prince  Jost  of  Lippe- 
Biesterfeld,  each  bore  21  children. 

The  so-called  two-children-system  obtains  most  commonly  in 
France. 

It  is  true  that  even  in  France  there  are  on  an  average  nearly 
three  children  born  per  marriage;  but  if  we  take  into  account  sur- 
viving children  only  we  find  an  average  per  family  of  2.1  children 
only.  Similar  conditions  obtain  in  New  England,  and  in  Transyl- 
vania; and  the  same  practice  is  spreading  throughout  the  United 
States. .  Another  way  in  which  the  attempt  is  made  to  keep  down 
the  population  is  that  customary  in  Alsace,  where,  if  there  are 
several  children  in  a  family  one  only  marries,  in  order  to  avoid  a 
division  of  the  family  property.  It  cannot  be  denied  that  in  France, 
doubtless  in  consequence  of  the  two-children  system,  a  somewhat 
widely  diffused  prosperity  exists,  a  prosperity  which  is  lacking  in 
the  rare  districts  in  France,  such  as  Brittany,  in  which  limitation  of 
the  family  is  not  practised.  What  a  disastrous  influence  the  general 
use  of  measures  for  the  prevention  of  pregnancy  exercises  on  the 
military  power  and  political  status  of  a  nation  has,  however,  in 
recent  years  been  made  especially  manifest  in  the  case  of  France. 
In  that  country,  of  ten  million  families,  two  million  are  absolutely 
childless,  and  two  million  have  only  one  child  each,  so  that  two- 
fifths  of  the  French  families  are  as  good  as  inactive  in  maintaining 
the  population  of  the  country.  The  injury  thus  done  to  France  is 
shown  still  more  clearly  by  a  tabular  comparison  of  the  excess  of 
births  over  deaths  in  the  German  and  French  nations,  respectively, 
during  the  two  decades  1874  to  1894  (from  G.  von  Mayr's  Popula- 
tion Statistics). 


THE  SEXUAL  EPOCH  OF  THE  MENACME.  385 

Year.  Germany.  France. 

+  4-8 
.      2.9 
3-6 

3-9 
2.6 

2-5 

2-9 

2.6 
2.6 
2-3 


1874  

+13-4 

1875  

13-0 

1876  

14.6 

1877  

13-6 

1878.,  

12.7 

1879  

13-3 

1880  

ii.  6 

1881  

n-5 

1882  

11.5 

1883  

1884  

II.  2 

1885  

u-3 

1886...  

10.8 

1887  

12.7 

1888  

12.9 

1889  

12.7 

1890  

n-3 

1891  

13-6 

1892  

u-7 

1893  

12.2 

1894  

13-6 

I  .  2 

—0.3 

+  0.1 
1  .2 

To  what  an  extent  in  all  times,  and  among  all  peoples,  the  fer- 
tility of  women  was  esteemed,  is  shown  by  religious  writings  and 
traditional  customs  which  aimed  at  enabling  a  wife  who  had  had 
no  children  by  her  own  husband,  to  seek  other  conjugal  embraces. 
Among  the  Jews,  it  was  the  duty  of  a  man  to  marry  his  widowed 
and  childless  sister-in-law;  if  he  were  unwilling  or  unable  to  per- 
form this  duty  he  was  compelled  to  take  a  part  in  a  ritual  termed 
"  chaliza,"  in  which  his  foot  was  bared  and  the  bereaved  woman 
spat  upon  him,  because  he  was  unwilling  to  maintain  his  brother's 
house.  In  the  law  book  of  the  Hindoos  of  Manus,  we  read,  "If 
husband  and  wife  have  no  children,  it  is  proper  for  them  to  obtain 
the  desired  offspring  by  a  union  between  the  wife  and  the  husband's 
brother,  or  some  other  relative ;"  the  child  obtained  in  this  way 
was  legally  regarded  as  the  child  of  the  husband.  Confucius  wrote: 
"  If  your  wife  is  barren,  take  a  second  wife;  she  must  be  subordi- 
nate to  the  first  wife,  for  her  only  duty  is  the  bearing  of  children." 
An  analogy  to  this  ordinance  is  to  be  found  in  the  Bible ;  Abra- 
ham's barren  wife  Sarai  says  to  Abraham :  "  Behold  now,  the  Lord 
has  restrained  me  from  bearing :  I  pray  thee,  go  in  unto  my  maid ; 
it  may  be  that  I  may  obtain  children  by  her.  And  Abraham  heark- 
ened unto  the  voice  of  Sarai."  In  the  same  way  the  barren  Rachel 
speaks  to  her  husband  Jacob,  "  Behold  my  maid  Billah,  go  in  unto 
her;  and  she  shall  bear  upon  my  knees,  that  I  may  also  have  chil- 
dren by  her." 

Luther,  in  his  treatise  on  marital  love  published  in  the  year  1522, 
bases,  doubtless  on  the  above  biblical  precedents,  the  following  state- 
25 


386  THE  SEXUAL  LIFE  OF  WOMAN. 

ment  regarding  fertility:  "If  a  sexually  potent  woman  is  married 
to  an  impotent  man,  if  she  is  unable  to  take  any  other  man  openly, 
yet  is  unwilling  to  do  anything  dishonourable,  she  should  say  to  her 
husband,  '  Dear  husband,  you  cannot  fulfil  your  duty  to  me,  and 
you  have  deceived  my  young  body,  you  have  endangered  my  honour 
and  my  happiness,  and  in  the  eye  of  God  our  marriage  is  null,  for- 
give me  therefore  if  I  form  a  secret  union  with  your  brother  or 
with  your  "nearest  friend ;  the  fruit  of  this  union  will  be  yours  in 
name,  thus  your  possessions  will  not  fall  to  strangers,  and  you  will 
willingly  allow  me  to  deceive  you,  because  involuntarily  you  have 
deceived  me." 

In  ethnography,  the  term  endogamy  is  used  to  denote  a  law  or 
custom  by  which  marriage  is  allowed  only  within  the  limits  of  a 
specified  race,  tribe,  or  caste;  thus,  in  the  Old  Testament,  Jews  are 
forbidden  to  marry  women  of  other  races.  The  ethnographical 
term  exogamy  indicates  the  prohibition  of  marriage  between  per- 
sons who  are  more  closely  allied,  as,  for  instance,  the  Mosaic  pro- 
hibition of  marriage  within  certain  degrees  of  blood-relationship. 
Such  exogamic  prohibitions  persist  even  in  the  legislation  of  the 
present  day.  In  many  ecclesiastical  and  national  laws-  we  find  the 
marriage  of  first  cousins  and  of  uncle  or  aunt  with  niece  or  nephew 
forbidden;  and  even  a  prohibition  of  the  marriage  of  a  man  with 
his  deceased  wife's  sister. 

Hegar  considers  the  danger  of  inbreeding  to  be  very  great  in 
the  human  species ;  for  whereas  in  the  lower  animals  breeders 
employ  a  methodical  and  carefully  considered  selection  of  the  best 
specimens,  nothing  of  this  kind  occurs  among  human  beings;  and 
the  health  of  modern  civilized  man  is  such  that  there  are  few 
families  without  a  skeleton  in  the  closet.  "  Not  only  in  families, 
but  also  in  villages,  in  small  and  large  towns,  even  in  classes,  and 
in  entire  nations,  certain  peculiar  qualities,  morbid  tendencies,  and 
predispositions,  are  handed  down  from  generation  to  generation. 
We  have,  for  instance,  the  tendency  of  the  Jews  to  nervous  disor- 
ders and  diabetes,  that  of  the  English  to  gout,  that  of  the  Germans 
to  myopia."  Sirahan  has  therefore  employed  the  term  "  social  con- 
sanguinity," to  indicate  that  by  means  of  common  customs,  environ- 
ment, occupation,  and  mode  of  nutrition,  a  similarity  in  type  is  pro- 
duced, leading  to  a  similar  predisposition  to  disorders  and  diseases 
transmissible  from  father  to  son. 

The  dangers  of  inbreeding  are  believed  by  He  gar  to  be,  under 
present-day  conditions,  so  considerable  that  he  would  allow  the  mar- 


THE  SEXUAL  EPOCH  OF  THE  MENACME.  387 

riage  of  near  kin  in  exceptional  cases  only,  and  where  the  circum- 
stances are  peculiarly  favourable  —  for  instance,  where  both  parties 
to  the  projected  marriage  are  in  excellent  health,  and  where  there 
is  no  great  similarity  between  them  in  feature  or  mental  type. 
Certain  anomalies  transmitted  from  remote  ancestors,  dependent  on 
deeply-marked  peculiarities  of  the  germ  cells,  may  be  so  developed 
by  inbreeding  as  to  become  absolutely  fixed  characteristics.  If  the 
morbid  manifestations  can  be  traced  back  for  several  generations, 
if  the  bodily  defects  and  disturbances  of  development  (the  so-called 
stigmata  of  degeneration),  are  well  marked  and  numerous,  if  the 
functional  disorders  of  the  nervous  system  and  of  the  sense  organs 
are  pronounced,  leading  to  idiocy,  insanity,  epilepsy,  congenital  deaf- 
mutism,  blindness,  instinctive  criminality, —  there  is  in  such  cases 
little  or  no  hope  of  the  regeneration  of  the  family.  It  dies  out, 
because  the  members  are  sterile;  because  they  are  confined  in 
prisons  or  asylums ;  or  because  the  children,  if  any  are  born,  are 
deficient  in  vitality,  and  fail  to  reach  maturity. 

According  to  the  brief  summary  of  the  subject  given  by  He  gar, 
the  peculiarities  of  the  offspring  at  the  time  of  birth  depend  upon: 

Factors  which  give  rise  to  peculiarities  of  the  germ-cells: 
I.  Germinal  rudiments  derived  from  the  ancestors; 
II.  Influences   acting   on   the  germ-cells    within   the   parent 
organism ; 

a.  Owing  to  peculiarities  of  the  fluids  and  tissues  of  the 

parental  body; 

b.  Owing  to   substances  which   penetrate   the   parental 

body  and  reach  the  germ. 

Germinal  rudiments  altered  by  the  conjugation  of  the  male  and 
female  reproductive  cells : 

I.  On  the  mother's  side ; 

a.  Owing  to  peculiarities  of  the  fluids  and  tissues  of  the 

maternal  body ; 

b.  Owing  to  substances   which  penetrate  the,  maternal 

organism  and  reach  the  fertilized  ovum. 

II.  On  the  father's  side,  owing  to  substances  which  adhere 

to   the   paternal   reproductive    cells,  or   are    enclosed 

within  these. 

The  number  of  consanguineous  marriages  at  the  present  day  is 
not  less  than  5^2  to  6l/2  per  1,000;  the  fertility  of  these  marriages 
appears  to  be  identical  with  the  fertility  of  ordinary  marriages. 
Mayet  has  made  a  statistical  investigation  to  determine  the  influence 


388  THE  SEXUAL  LIFE  OF  WOMAN. 

of  consanguineous  marriages  in  the  pathogenesis  of  mental  disease. 
He  finds  that  the  number  of  those  congenitally  affected  with  mental 
disorder  is  twice  as  great  in  the  offspring  of  consanguineous  mar- 
riages as  in  the  offspring  of  crossed  marriages;  in  the  case  of 
simple  mental  disorder,  of  paralytic  dementia,  and  of  epileptic 
dementia,  the  ratio  is  actually  greater  than  two  to  one  (the  actual 
figures  are  218,  257,  208:  100).  Thus  we  see  that  when  there  ex- 
ists any  cause  of  inheritable  mental  disorder,  blood-relationship  of 
the  parents  more  than  doubles  the  danger  to  the  children.  In  the 
case  of  imbecility  and  idiocy  the  danger  is  less  in  this  respect  (the 
ratio  is  150:  100)  ;  the  factor  of  inheritance  plays  a  less  promi- 
nent part  than  in  the  case  of  other  psychoses. 

It  was  remarkable  that  among  the  offspring  of  marriages  of 
nephew  and  aunt,  cases  of  mental  disorder  were  almost  entirely 
lacking.  Among  the  offspring  of  marriages  of  uncle  and  niece,  the 
inheritance  of  mental  disorder  was  more  prominent  than  among 
the  children  of  first  cousins.  It  is  interesting  to  determine  the  in- 
fluence of  blood-relationship  in  cases  in  which  the  existence  of  in- 
heritable predisposition  could  not  be  proved.  In  these  cases,  as 
regards  simple  insanity,  paralytic  dementia,  and  epileptic  dementia, 
the  number  of  cases  among  the  offspring  of  consanguineous  mar- 
riages was  only  one-half  as  compared  with  the  offspring  of  crossed 
marriages ;  whereas  in  the  case  of  imbecility  and  idiocy  this  ratio 
was  reversed.  In  idiocy,  where  inheritance  generally  speaking  plays 
a  small  part,  the  origination  of  the  disease  would  often  appear  to 
depend  directly  on  the  blood-relationship  of  the  parents ;  whilst  as 
regards  other  forms  of  mental  disorder,  if  there  is  no  inheritable 
predisposition,  blood  relationship  in  the  parents  appears  to  be  a 
positive  advantage;  where,  however,  a  family  predisposition  to  in- 
sanity exists  the  likelihood  of  actual  insanity  appearing  in  the  off- 
spring is  notably  enhanced  by  a  consanguineous  marriage. 


The  Restriction  of  Fertility  and  the  Use  of  Means  for  the  Pre- 
vention of  Pregnancy. 

As  we  have  already  pointed  out,  a  restriction  of  the  fertility  of 
women  occurs  in  the  majority  of  marriages,  to  this  extent,  tha-t  the 
potential  reproductive  powers  of  the  wife  are  not  fully  utilized.  In 
recent  times,  however,  the  restriction  of  fertility,  by  the  deliberate 
use  of  measures  for  the  prevention  of  pregnancy,  has  become  so 
widely  diffused,  that  it  appears  unwise  from  the  scientific  stand- 


THE  SEXUAL  EPOCH  OF  THE  MENACME.  389 

point  simply  to  ignore  the  question,  and  it  has  become  indispensable 
to  study  how  the  practice  developed,  and  to  consider  what  are  its 
actual  results.  From  our  own  point  of  view,  it  is  the  more  neces- 
sary to  do  this,  for  the  reason  that  the  use  of  preventive  measures 
has  come  to  play  an  important  part  in  the  sexual  life  of  woman, 
and  therefore  deserves  the  fullest  attention,  not  merely  from  the 
standpoint  of  the  sociologist,  but  in  addition  from  the  purely  medical 
point  of  view. 

In  many  divisions  of  the  population,  and  even  in  entire  nationali- 
ties, the  prevention  of  pregnancy,  not  merely  in  illicit  intercourse, 
but  also  in  married  life,  has  become  so  general"  a  practice  that  the 
fertility  of  the  nation  as  a  whole  has  been  profoundly  modified. 
Thus,  in  France  at  the  present  day,  the  average  number  of  children 
per  marriage  is  less  than  two ;  and  the  two-children-system  is  almost 
universally  practised  in  Transylvania  and  Norway,  whilst  it  is  very 
rapidly  spreading  in  North  America.  In  the  principal  towns  of  the 
whole  of  Europe,  this  system  is  largely  on  the  increase  among  the 
upper  classes  of  society.  The  marriages  of  the  poor,  partly  owing 
to  ignorance,  and  partly  to  indolence,  are  as  yet  comparatively  little 
affected  by  this  depopulative  principle. 

In  the  days  of  antiquity,  many  lawgivers  endeavoured  to  set 
bounds  to  excessive  fertility,  and  artificial  abortion  was  methodically 
practised  by  those  who  wished  to  avoid  an  inconveniently  large 
family.  Even  among  savage  peoples,  we  find  that  certain  preventive 
measures  are  occasionally  employed  in  sexual  intercourse.  Among 
civilized  peoples,  however,  until  the  beginning  of  the  nineteenth  cen- 
tury, religious  and  moral  ideas  derived  from  the  Bible  continued  to 
dominate  the  sexual  life.  It  is  well  known  that  Old  Testa- 
ment law  and  Christian  morality  alike  forbid  any  artificial  restric- 
tion of  human  increase.  "  Increase  and  multiply  "  was  the  com- 
mand given  in  Genesis  to  the  first  parents  of  the  race;  and  the 
psalmist  exclaims,  "  Happy  is  the  man  that  hath  his  quiver  full "  of 
children. 

A  remarkable  revolution  in  thought  was  initiated  toward  the  be- 
ginning of  the  nineteenth  century  by  the  great  philanthropist  and 
powerful  thinker,  Thomas  Robert  Malthus,  founder  of  the  doctrine 
of  the  propriety  of  checking  the  increase  of  population,  author  of 
the  work  "An  Essay  on  the  Principle  of  Population,"  London, 
1798,  whose  Law  of  Population  soon  attracted  world-wide  atten- 
tion. Modern  civilization  having  greatly  increased  the  cost  of 
bringing  up  a  family,  while  simultaneously  there  has  been  a  general 


390  THE  SEXUAL  LIFE  OF  WOMAN. 

rise  in  the  price  of  the  necessaries  of  life,  there  has  resulted  an 
extraordinary  diffusion  of  Malthusianism ;  in  comparison  with  the 
causes  just  alluded  to  for  the  use  of  preventive  measures,  diseases 
which  render  renewal  of  pregnancy  dangerous  to  the  mother's  life 
have  comparatively  little  to  do  with  the  causation  of  voluntary 
sterility. 

In  his  "Essay  on  the  Principle  of  Population,"  Mai  thus  indi- 
cates, as  the  cause  which  has  hitherto  hindered  mankind  in  the 
pursuit  of  happiness,  the  unceasing  tendency  of  all  organic  life  to 
increase  in  excess  of  the  means  of  subsistence.  In  the  case  of 
plants  and  of  unreasoning  animals,  the  natural  process  is  a  very 
simple  one.  Both  animals  and  plants  are  impelled  by  a  powerful 
instinct  to  reproduce  their  kind,  and  the  operation  of  this  instinct 
is  quite  undisturbed  by  any  anxiety  regarding  the  livelihood  of  their 
offspring.  The  reproductive  function  is  thus  exercised  at  every 
available  opportunity,  and  the  superfluous  individuals  of  the  next 
generation  are  destroyed  by  lack  of  space  and  nutriment.  In  the 
human  species  the  restriction  of  population  is  effected  by  a  more 
complex  mode  of  operation.  Man  is  impelled  to  reproduce  his  kind 
by  an  instinct  not  less  powerful  than  that  of  other  animals;  but  the 
gratification  of  this  instinct  is  checked  by  reason,  which  makes  him 
ask  himself  whether  he  is  not  about  to  bring  into  the  world  beings 
for  whom  he  will  be  unable  to  provide  the  means  of  subsistence. 
If  he  is  influenced  by  this  consideration,  the  resulting  restriction  of 
population  may  often  entail  serious  consequences;  if,  on  the  other 
hand,  he  gratifies  his  instinct,  regardless  of  the  appeal  of  reason, 
the  human  species  will  inevitably  tend  to  increase  more  rapidly  then 
the  means  of  subsistence. 

Mai  thus  declared  that  population,  when  its  increase  was  unre- 
stricted, doubled  itself  every  twenty-five  years,  and  therefore  in- 
creased in  a  geometrical  progression ;  he  considered  that  in  the  most 
favourable  circumstances  the  means  of  subsistence  could  not  pos- 
sibly increase  more  rapidly  than  in  an  arithmetical  progression. 
The  contrast  between  these  two  modes  of  increase  will  be  more 
striking  if  we  write  out  the  actual  figures.  According  to  the  theory 
of  Malthus,  the  increase  of  human  population  would  be  represented 
by  the  figures  I,  2,  4,  8,  16,  32,  64,  128,  256,  whereas  the  simul- 
taneous increase  in  the  means  of  subsistence  would  be  represented 
by  the  figures  i,  2,  3,  4,  5,  6,  7,  8,  9.  Such  an  increase  in  popula- 
tion is,  however,  always  prevented  by  certain  checks,  classed  by 
Malthus  as  of  two  kinds,  preventive  checks  and  positive  checks. 


THE  SEXUAL  EPOCH  OF  THE  MENACME.  391 

A  preventive  check,  in  so  far  as  it  is  voluntary,  is  peculiar  to 
the  human  species,  and  originates  in  the  intellectual  faculty  which 
enables  man  to  foresee  the  consequences  of  his  actions.  A  man 
who  looks  around  him,  and  sees  the  poverty  into  which  those 
with  large  families  so  often  fall,  who  reckons  up  his  present  prop- 
erty or  earnings,  which  barely  suffice  to  provide  for  his  own  per- 
sonal necessities,  cannot  fail,  when  he  considers  how  hardly  they 
would  suffice  for  seven  or  eight  additional  persons,  to  doubt  whether 
it  would  be  possible  for  him  to  provide  for  the  offspring  he  might 
bring  into  the  world.  Such  considerations  as  these  are  likely  to 
lead  a  large  number  of  persons  of  all  civilized  nations  to  resist 
their  natural  instincts,  and  to  refrain  from  early  marriage.  If  ab- 
stinence entailed  no  serious  consequences,  it  would  be  the  least  of 
all  evils  resulting  from  the  principle  of  population. 

The  positive  checks  to  increase  of  population  are  manifold,  and 
embrace  all  the  causes  which  are  competent  to  lessen  the  natural 
duration  of  human  life.  Among  these  we  may  enumerate:  all  un- 
healthy occupations,  severe  toil,  climatic  conditions,  poverty,  errors 
in  the  rearing  of  children,  town  life,  excesses  of  all  kinds,  the  whole 
army  of  illnesses  and  epidemics,  war,  pestilence,  and  famine.  In 
all  countries,  preventive  and  positive  checks  are  more  or  less  power- 
fully operative,  and  yet  there  are  few  in  which  the  population  is  not 
continually  tending  to  increase  beyond  the  means  of  subsistence.  As 
a  further  consequence  of  this  tendency  of  population  to  increase,  we 
observe  the  wider  diffusion  of  poverty  among  the  lower  classes,  so 
that  any  permanent  improvement  in  their  condition  is  rendered  im- 
possible. 

After  Malthus  had  carefully  stated  his  thesis,  he  gave  a  summary 
record  of  the  conditions  of  population  in  nearly  all  nations  of  the 
past  and  of  his  own  time,  in  order  to  show  how  in  all  alike  the 
three  principal  means  of  limiting  population,  moral  restraint,  dis- 
ease, and  poverty,  had  been  in  continuous  operation. 

He  showed,  for  instance,  how  the  population  of  the  South  Sea 
Islands  had  been  limited  by  certain  conditions,  cannibalism,  castra- 
tion of  the  males,  infibulation  of  the  females,  late  marriages,  the 
sanctification  of  virginity,  contempt  for  marriage,  etc. 

In  ancient  Greece,  Solon's  laws  permitted  infanticide.  Plato,  in 
"  The  Republic  "  asserts  that  it  is  the  duty  of  the  Government  to 
regulate  the  number  of  the  citizens,  and  to  prevent  an  immoderate 
increase ;  men  and  women  should  be  allowed  to  procreate  only  dur- 
ing their  period  of  maximum  strength,  all  weakly  children  should  be 


392  THE  SEXUAL  LIFE  OF  WOMAN. 

killed.  Aristotle  advised  that  men  should  not  be  allowed  to  marry 
before  the  age  of  37,  and  women  before  the  age  of  18;  the  women 
should  give  birth  to  a  limited  number  of  children  only;  if,  after  this, 
they  again  became  pregnant,  abortion  should  be  induced.  He  main- 
tained that  if  all  were  at  liberty,  as  was  the  case  in  most  countries, 
to  bring  into  the  world  as  many  children  as  they  pleased,  poverty, 
the  mother  of  crime  and  insurrection,  must  inevitably  ensue. 

Among  the  Romans  war  was  as  a  positive  check  unceasingly 
operative :  in  this  time  of  the  Empire,  preventive  methods  came  into 
general  use,  in  the  form  of  various  kinds  of  sexual  perversity. 
Juvenal  complains  of  the  skilled  methods  employed  in  the  induction 
of  abortion;  during  the  later  period  of  the  Roman  Empire,  sexual 
morality  became  so  degenerate  that  marriage  was  hated  and  de- 
spised. 

Passing  to  the  consideration  of  the  checks  on  population  among 
the  nations  of  modern  Europe,  Malthus  examined  the  registers  of 
marriages  and  deaths,  and  came  to  the  conclusion  that  in  few 
countries  is  the  mass  of  people  sufficiently  capable  of  self-restraint 
to  postpone  marriage  until  they  are  reasonably  assured  of  being 
able  to  provide  for  all  the  children  they  are  likely  to  have ;  still,  he 
ascertained  that  at  the  present  day  positive  checks  on  population 
were  less  active,  and  preventive  checks  more  active,  than  in  earlier 
times  and  among  savage  races. 

Malthus  did  not  base  upon  his  conclusions  the  advice  that  in 
sexual  intercourse  means  of  preventing  pregnancy  should  be  em- 
ployed, as  the  modern  "  Malthusians  "  advise ;  in  his  eyes,  moral 
restraint,  that  is  to  say,  sexual  abstinence,  was  the  only  remedy  for 
the  prevention  of  poverty  and  the  other  evil  consequences  of  the 
principle  of  population-  Moral  restraint  was  in  his  opinion  the 
only  virtuous  method  of  avoiding  the  evils  of  excessive  fertility.  It 
is  a  man's  duty  not  to  marry  until  he  had  a  definite  prospect  of  be- 
ing able  to  maintain  his  children ;  the  interval  between  puberty  and 
marriage  must  be  passed  in  strict  chastity.  Alan's  duty  is  not  the 
mere  reproduction  of  his  species,  but  the  reproduction  of  virtue  and 
happiness,  and  if  he  is  not  able  to  do  the  latter,  he  has  no  right 
whatever  to  do  the  former.  Malthus  lays  great  stress  on  educating 
the  people  in  this  matter;  "in  addition  to  the  ordinary  subjects  of 
instruction,  it  is  necessary  to  explain  the  principle  of  population, 
and  the  manner  in  which  it  gives  rise  to  poverty."  In  the  nature 
of  the  case,  no  lasting  and  general  improvement  in  the  condition  of 
the  poor  is  possible  without  an  increase  in  the  preventive  restric- 
tion of  population. 


THE  SEXUAL  EPOCH  OF  THE  MENACME.  393 

The  Malthusian  doctrine  of  the  law  of  population  gave  rise  to 
an  enormous  sensation,  and  some  of  his  disciples  soon  proceeded  to 
translate  his  conclusions  into  practice ;  such '  authorities  as  James 
Mill  and  Francis  Place  recommended  measures  by  means  of  which, 
"  without  any  injury  to  health,  or  to  the  feminine  sense  of  deli- 
cacy, conception  can  be  prevented : "  the  avowed  aim  of  these 
measures  was  to  prevent  the  increase  of  population  beyond  the 
means  of  subsistence.  Physicians  and  physiologists  joined  the 
ranks  of  these  innovators;  among  others  Raciborski,  Robert  Dale 
Owen  in  his  "  Moral  Physiology,"  Richard  Carlile  in  his  "  Book 
of  Woman,"  the  first  work  to  give  an  exact  description  of  the 
means  to  employ  for  the  prevention  of  conception,  Knozvlton  in  his 
"  Fruits  of  Philosophy."  In  the  year  1827  in  the  Northern  counties 
of  England  leaflets  were  for  the  first  time  distributed  among  the 
working  classes  to  instruct  them  in  the  use  of  preventive  measures. 
Bradlangh  founded  the  Malthusian  Society,  which  aimed  at  the 
dissemination  of  instruction  in  the  use  of  preventive  methods.  There 
is  now  in  England  a  "  Malthusian  League,"  numbering  leading  phy- 
sicians among  its  members ;  this  supplies  to  cill  classes  the  means  by 
which  the  family  can  be  artificially  limited.  A  new  edition  of  the 
above-mentioned  book,  "  The  Fruits  of  Philosophy,"  was  circulated 
in  London  in  an  edition  of  several  hundred  thousand  copies,  and 
prominent  persons  spoke  at  congresses  on  the  subject  of  Neo- 
Malthusianism.  In  Germany,  also,  a  "  Union  of  Social  Harmony  " 
was  founded,  for  the  free  distribution  of  a  hand-book  on  the  use 
of  measures  for  the  prevention  of  conception,  and  for  an  in- 
vestigation regarding  the  results  of  these. 

We  do  not  propose  here  to  subject  the  teaching  of  Malthus  to  a 
critical  examination ;  he  has  found  formidable  opponents,  who  have 
endeavoured  to  prove  that  his  fundamental  assumption  is  false ; 
they  maintain  that  work  or  the  power  of  work  increases  in  direct 
ratio  with  the  population ;  and  they  also  assert  that  population 
tends  to  increase,  not,  as  Malthus  maintained,  in  a  geometrical,  but 
simply  in  an  arithmetical  progression.  We  shall  merely  quote 
Liebig's  reply  to  the  law  of  Malthus,  "  when  human  labour  and 
manure  are  provided  in  sufficient  quantity,  the  soil  is  inexhaustible, 
and  will  continue  to  yield  unceasingly,  the  most  abundant  har- 
vests ;"  and  Rodbertus'  remark  that  "  agricultural  chemistry 
will  ultimately  be  competent  to  create  nutritive  materials ;  this 
will  some  day  be  just  as  much  within  the  power  of  society,  as  it 
is  at  present  to  provide  any  requisite  quantity  of  textiles,  given  the 


394  THE  SEXUAL  LIFE  OF  WOMAN. 

necessary  amount  of  raw  material."  The  celebrated  socialist  Bebcl, 
is  a  strong  opponent  of  Mai  thus.  He  writes :  "  The  earth  is  doubt- 
less thickly  populated,  but  none  the  less  only  a  small  fraction  of  its 
surface  is  occupied  and  utilized.  Not  merely  could  Great  Britain 
produce,  as  has  been  proved,  a  far  larger  supply  of  nutritive  mater- 
ials than  at  present,  but  the  same  is  true  of  France,  Germany  and 
Austria,  and  in  a  still  higher  degree  of  the  other  countries  of  Eu- 
rope. European  Russia,  were  it  as  thickly  populated  as  Germany, 
could  support,  instead  of  ninety  millions,  as  at  present,  a  population 
of  four  hundred  and  seventy-five  millions.  For  the  purposes  of  the 
higher  civilization,  toward  which  we  are  striving,  we  have  to-day  in 
Europe,  and  shall  have  for  a  long  time  to  come,  not  an  excess  of 
population,  but  an  insufficiency,  and.  every  day  brings  new  discover- 
ies and  inventions  whereby  the  means  of  subsistence  are  poten- 
tially increased.  In  other  parts  of  the  world,  the  insufficiency  of 
population  and  the  superfluity  of  ground  are  even  more  noticeable. 
Carey  is  of  opinion  that  the  single  valley  of  the  Orinoco,  fifteen 
hundred  miles  in  length,  would  suffice  to  provide  nutritive  material 
in  sufficient  quantities  to  feed  the  whole  existing  population  of  the 
world.  Central  and  South  America,  and  more  especially  Brazil, 
have  a  soil  of  extraordinary  fertility,  but  are  as  yet  practically  un- 
utilized by  the  world.  To  increase,  not  to  diminish,  the  numbers  of 
the  human  race,  that  is  the  appeal  made  by  civilization  to  man- 
kind!" A  similar  position  on  this  question  was  recently  taken  by 
Roosevelt,  the  President  of  the  United  States,  himself  the  father  of 
six  children,  in  a  letter  to  two  American  women,  Mrs.  J.  and 
M.  Van  Vorst,  authors  of  the  book  "  Woman  Who  Toils 
(Factory  Life  in  America)."  In  this  book,  the  writers  prove  that 
in  the  United  States  the  average  size  of  the  family  is  now  less 
than  in  any  other  country  of  the  world,  France  alone  excepted. 
President  Roosevelt,  in  his  letter,  declares  himself  an  ardent  sup- 
porter of  the  biblical  injunction,  "increase  and  multiply!"  He 
writes :  "  Whoever  evades  his  responsibilities,  through  desire  for 
independence,  convenience,  and  luxury,  commits  a  crime  against 
the  race  to  which  he  belongs,  and  should  be  an  object  of  contempt 
and  horror  to  a  healthy  nation.  When  men  avoid  becoming  fathers 
of  families,  and  when  women  cease  to  regard  motherhood  as  the 
most  important  career  open  to  them,  the  nation  to  which  these  men 
and  women  belong  has  cause  for  uneasiness  about  its  future." 
President  Roosevelt  continues :  "  To  the  American  woman  mar- 
riage is  no  longer  a  life-duty,  a  profession,  as  it  is  to  her  sisters 


THE  SEXUAL  EPOCH  OF  THE  MENACME.  395 

who  are  members  of  the  older  civilizations.  A  woman  who  man- 
ages an  extensive  business,  who  supervises  her  own  landed  property, 
or  who  plays  her  own  part  in  the  world  of  finance, —  for  such  as 
these,  the  '  lottery  of  marriage  '  is  naturally  something  they  dread 
rather  than  desire."  President  Elliott,  of  Harvard  College,  has  ex- 
pressed similar  views  in  a  speech  on  this  subject.  He  deplores  the 
late  marriages  and  small  families  of  the  cultured  Americans.  Ac- 
cording to  the  last  census,  an  American  family  has  on  the  average 
less  than  three  children ;  twenty  years  ago  the  average  number  was 
from  four  to  five  children. 

I  pass  now  to  consider  the  medical  point  of  view  of  this  question 
of  the  prevention  of  pregnancy.  It  is  my  opinion  that  the  physician 
as  such  should  intervene  in  the  matter,  not  in  any  case  for  the  re- 
lief of  the  dominant  economic  parental  dread  of  insufficient  means 
for  the  upbringing  of  children,  but  only  on  account  of  the  purely 
medical  consideration  of  the  physical  dangers  of  motherhood.  That 
is  to  say,  the  physician  should  lend  his  skilled  assistance  toward 
the  attainment  of  facultative  sterility,  only  when  his  own  special 
scientific  knowledge  leads  him  to  consider  this  urgently  necessary ; 
it  is  not  his  province  to  assist  in  preventing  the  birth  of  an  im- 
moderate number  of  offspring;  his  intervention  is  justified  only 
when  deliberate  reflection  has  convinced  him  that  his  patient's  health 
or  life  would  be  endangered  by  pregnancy  or  child-birth.  A  woman's 
life  and  well-being  must  appear  to  him  of  greater  importance  than 
the  existence  or  non-existence  of  a  possible  infant.  That  this  view 
is  morally  sound,  is  shown  by  the  fact  that  public  opinion  justifies 
the  accoucheur  in  the  destruction  of  an  already  living  child,  when 
the  mother's  life  is  endangered.  In  this  connection  we  may  recall 
the  words  of  the  great  Napoleon ;  the  physician  Dubois,  attending 
Marie  Louise  in  a  difficult  confinement,  asked  Napoleon  whether, 
if  matters  came  to  an  extremity,  he  should  save  the  mother  or  the 
child ;  Napoleon,  notwithstanding  his  strong  desire  for  the  birth  of 
an  heir  to  his  dynasty,  replied,  "  The  mother,  it  is  her  right." 

In  isolated  cases,  which  deserve  always  very  serious  consideration, 
some  pathological  condition  in  the  wife  may  justify  the  prevention 
of  pregnancy.  In  certain  very  serious  general  disorders,  in  diseases 
of  the  heart  or  of  the  lungs,  in  pelvic  deformity,  and  in  pathological 
changes  of  the  female  reproductive  organs,  it  may  be  right  to  employ 
means  for  the  prevention  of  pregnancy  —  not  merely  sexual  absti- 
nence, but  actual  measures  to  prevent  fertilization. 

The  misuse  of  medical  knowledge  for  the  recommendation  or  em- 
ployment of  preventive  measures,  on  the  ground  of  humanitarian 


396  THE  SEXUAL  LIFE  OF  WOMAN. 

sentiment  or  social  and  economic  considerations,  must,  however,  be 
strongly  resisted.  Even  leading  gynecologists  have  erred  in  this 
way.  Sanger  writes,  "  Scientifically-trained  accoucheurs  will  do 
much  more  to  promote  the  health  and  well-being  of  women,  and  to 
protect  them  from  sexual  and  other  diseases,  than  the  humanitarian 
efforts  of  the  Neo-MaJthusians,  who  transfer  a  purely  scientific 
question,  such  as  the  disproportion  between  the  number  of  births 
and  the  supply  of  nutritive  material,  to  the  sphere  of  medicine,  re- 
garding themselves  as  justified  in  preventing  conception  whenever 
they  please,  independently  of  considei  ations  relating  to  the  health 
of  the  mother  *******  ** 
A  woman  exhausted  by  frequent  child-bearing,  anaemic  and  suffer- 
ing, is  certainly  a  figure  to  arouse  everyone's  sympathy ;  in  so  far  as 
she  is  ill  in  consequence  of  injury  received  in  child-birth,  it  is  our 
duty  to  prevent  further  injury,  and  to  relieve  to  the  best  of  our 
ability  that  which  has  already  occurred;  in  so  far,  however,  as  she 
is  not  suffering  from  any  affection  of  the  reproductive  organs,  but 
is  ill  owing  to  the  lack  of  sufficient  food,  or  from  overwork, 
it  is  the  duty  of  society  to  render  assistance.  Here  we  have  to  do 
with  the  social  problem;  the  solution  of  which  will  be  brought  no 
nearer  by  the  use  of  the  occlusive  pessary."  Fehling  also  maintained 
that  a  text-book  of  gynecology  is  not  the  proper  place  in  which  to 
pass  judgment  on  so  important  a  socio-political  question.  The  busi- 
ness of  the  gynecologist  in  this  matter  is  merely  to  say  a  word  of 
caution  against  the  use  of  various  measures  which  are  so  often 
recommended  as  harmless,  but  are  in  fact  dangerous  to  the  woman 
who  uses  them. 

Kleimvachtcr,  who  declares  that  he  is  far  from  recommending  the 
use  of  preventive  measures  when  a  healthy  woman  wishes  to  save 
herself  the  trouble  of  child-bearing,  gives  as  legitimate  indications 
for  their  use:  i,  the  various  forms  of  severe  pelvic  deformity; 
2,  certain  tumours  in  the  pelvic  cavity;  3,  after  the  removal  of 
malignant  tumours  of  the  reproductive  organs,  certain  general  dis- 
orders, recently  arrested  pulmonary  tuberculosis,  organic  heart 
disease,  etc.  Regarding  these  cases,  Kleinw'dchter  writes:  "The 
wife's  life  would  be  endangered  by  pregnancy,  which  must  there- 
fore be  prevented  without  forbidding  coitus,  and  avoiding  the  prac- 
tice of  coitus  interruptus,  which  endangers  her  health,  or  of  any 
mode  of  intercourse  repugnant  to  the  feelings  of  wife  or  husband." 

The  most  trustworthy,  but  unquestionably  at  the  same  time  the 
least  practicable  method,  for  the  prevention  of  pregnancy,  is  that  of 


THE  SEXUAL  EPOCH  OF  THE  MENACME.  397 

Malthus  —  permanent  sexual  continence.  This  recommendation,  to 
which  Tolstoi  in  "  The  Kreuzer  Sonata  "  gives  his  adhesion,  has 
recently  found  an  advocate  in  a  modified  sense  in  a  distinguished 
gynecologist,  Hegar,  who  considers  that  the  great  fertility  of  the 
modern  civilized  countries  of  Europe  entails  many  disadvantages  — 
inferior  physical  development,  increased  general  mortality,  emi- 
gration, an  unfavourable  distribution  of  population  in  relation  to 
dwelling  and  occupation,  occasional  famine  —  and  who  sees  the 
only  effective  remedy  in  a  "  regulation  of  reproduction,"  whereby 
the  tendency  to  marriage  and  the  number  of  births  are  to  be  di- 
minished. The  question  "  when  is  the  number  of  children  in  a 
family  too  large  ?  "  is  answered  by  He  gar  as  follows  "A  maximal 
limit  is  easy  to  establish.  The  most  suitable  age  for  child-bearing 
is  from  twenty  to  forty.  At  an  earlier  and  a  later  age  than  this, 
both  the  mother  and  the  offspring  are  liable  to  suffer.  Between 
two  successive  births  there  should  be  an  interval  of  about  two  and  a 
half  years;  this  would  leave  time  for  the  birth  of  eight  children. 
If  we  assume  that  pregnancy  lasts  nine  months,  that  lactation  is 
continued  from  nine  to  twelve  months  after  delivery,  (and  if  the 
mother  does  not  herself  nurse  the  child,  artificial  feeding  or  careful 
supervision  of  the  wet-nurse  will  occupy  her  for  a  like  period),  to 
devote  an  additional  period  of  six  months  to  nine  months  to  the 
complete  restoration  of  the  mother's  health  cannot  be  regarded  as 
excessive.  For  this  maximum  family  we  assume  a  perfect  state  of 
health  on  the  part  of  the  mother,  a  pure  atmosphere,  and  a  sufficient 
supply  of  all  the  necessaries  of  life.  Illnesses,  weakness,  or  infirmity 
of  the  mother,  often  indicate  that  the  number  of  children  should  be 
further  limited.  It  is  easier  to  provide  a  suitable  dwelling  and  a 
pure  atmosphere  for  a  small  family  than  for  a  large  one.  The  same 
thing  is  true  as  regards  the  means  of  subsistence. 

"If  the  reproductive  function  is  to  be  intelligently  controlled," 
continues  Hegar,  "  above  all  it  is  necessary  to  devote  attention  to  the 
age  and  health  of  the  parents ;  but  occupation,  dwelling,  and  general 
environment,  must  also  not  be  overlooked.  Among  the  cultured 
classes  of  our  Fatherland,  people  are  gradually  learning  to  form 
sound  opinions  about  these  matters.  Among  the  working  classes, 
on  the  other  hand,  especially  among  those  engaged  in  factory 
labour,  the  heedless  gratification  of  the  sexual  impulse  is  responsible 
for  untold  misery."  Hegar' s  advice  may  be  summarized  as  follows : 
If  the.  marriage  takes  place  after  the  attainment  of  complete 
maturity,  in  the  wife  at  twenty  and  in  the  husband  at  twenty-five, 


398  THE  SEXUAL  LIFE  OF 

and  if  procreation  is  discontinued  in  the  wife  at  forty  and  in  the 
husband  at  forty-five  to  fifty,  if  between  successive  deliveries  the 
intervals  necessary  for  the  wife's  restoration  to  health  are  main- 
tained, if  illness  and  states  of  debility  are  taken  into  account,  if 
sickly,  hereditarily-tainted  individuals  are  forbidden  to  marry  —  the 
excessive  increase  in  population,  as  far  as  Germany  is  concerned, 
will  cease  to  give  cause  for  anxiety.  The  regulation  of  reproduc- 
tion will,  however,  still  be  incomplete,  unless  we  enforce  a  selection 
too  rigorous  for  our  present  views.  Moderation  and  continence 
must  aid  as  far  as  may  be  necessary  in  preventing  an  undue  in- 
crease in  population.  Hegar  does  not  fail  to  point  out  the  evil 
effects  of  an  excessive  limitation  of  the  family.  In  a  marriage  when 
one  child  only  is  born,  this  child  is  the  object  of  unceasing-  anxiety 
and  attention,  and  real  or  imaginary  dangers  assume  an  excessive 
importance  in  the  morbidly  excited  imagination  of  the  parents. 
Hence  we  find  a  continuous  excess  of  watchfulness  and  over-educa- 
tion in  the  case  of  the  only  child,  to  whom  independent  thought  and 
action  are  entirely  unknown.  Boys  become  milksops,  girls  nervous 
and  hysterical.  In  the  two-children-system,  again,  one  or  both  of 
the  children  may  die  when  the  age  of  the  parents  is  already  con- 
siderably advanced.  Still  in  those  districts  of  France  in  which  this 
system  obtains  the  population  is  well-to-do,  and  an  exceptionally 
large  proportion  of  the  males  are  fit  for  military  service.  The  use 
of  various  measures  for  the  prevention  of  conception  is  considered 
by  Hegar  to  be  harmful,  at  any  rate  in  the  case  of  young  women ; 
this  practice  gives  rise  to  anaemic  conditions,  and  to  nervous  weak- 
ness and  irritability,  seldom,  however,  to  more  serious  disorders,  as 
indeed  is  apparent  from  the  fact  that  the  mortality  of  married 
women  as  compared  with  unmarried  women  is  lower  in  France  than 
in  other  countries. 

Grdfe,  with  reference  to  the  view  that  if  for  any  reason  concep- 
tion must  be  prevented,  this  should  be  done  by  abstinence  from 
sexual  intercourse,  remarks :  "  Doubtless  an  ideal  demand,  but  one 
which  even  those  with  exceptional  strength  of  will  are  unlikely  to 
satisfy.  And  the  worst  of  it  is,  that  even  a  single  indiscretion  will 
often  result  in  impregnation.  Moreover,  it  is  distinctly  contrary  to 
natural  conditions,  that  a  healthy  married  couple  united  by  an  inti- 
mate affection  should  live  together  abstaining  completely  from  sex- 
ual intercourse.  The  question  has  already  been  much  discussed, 
both  in  speech  and  writing,  and  this  will  continue  in  the  future, 
without  altering  the  fact  that  the  physician  will  be  asked,  and  will  be 


THE  SEXUAL  EPOCH  OF  THE  MENACME.  399 

compelled  to  give,  advice  regarding  the  use  of  means  of  the  pre- 
vention of  pregnancy." 

Ribbing  writes,  "Although  the  sexual  impulse  is  the  product  of  a 
powerful  natural  developmental  force,  still  the  temporary,  and  some- 
times even  the  permanent,  control  of  this  impulse  is  a  moral  civiliz- 
ing force  of  enormous  importance."  This  writer  is  opposed  to  the 
use  of  artificial  preventive  measures;  he  considers  them  untrust- 
worthy and  dangerous  to  health.  Untrustworthy,  for  the  reason 
that  nature  has  endowed  living  organisms  with  a  strong  impulse 
toward  conjugation  and  has  equipped  with  very  powerful  forces  the 
processes  by  which  fertilization  is  effected.  Every  physician  is 
familiar  with  cases  in  which  preventive  measures  have  proved  in- 
effective. This  fact  is  proved  also  by  the  statistics  of  prostitution. 
Although  prostitutes  are  fully  instructed  in  the  use  of  preventive 
measures,  which  they  almost  universally  employ,  nevertheless  every 
year  a  smaller  or  larger  number  of  prostitutes  become  pregnant. 
These  measures  are  dangerous  to  health,  partly  because  of  their  in- 
terference with  natural  functions,  because  many  of  them  are  clumsy 
and  ill  adapted;  and  partly,  again,  because  owing  to  their  use  the 
woman  fails  to  enjoy  the  natural  periods  of  repose  which  are  en- 
tailed by  pregnancy,  parturition,  and  lactation.  Noteworthy  also  are 
the  psychical  considerations  adduced  by  Ribbing  against  the  use  of 
preventive  measures.  The  majority  of  well-bred  women  feel  deeply 
wounded  if  they  believe  themselves  to  be  regarded  merely  as  a 
means  of  enjoyment,  not  as  individuals,  as  persons  with  inalienable 
rights.  For  the  man  also  there  is  danger,  for  it  is  easy  for  him  to 
acquire  a  dislike  to  the  wife  who,  even  though  on  his  own  initia- 
tive, occupies  herself  with  the  technique  of  the  sexual  life  in  a  man- 
ner which  he  feels  instinctively  to  be  opposed  to  the  chastity  and 
puremindedness  demanded  by  every  man  from  his  wife.  Ribbing 
therefore  advises  a  certain  measure  of  sexual  abstinence  in  married 
life. 

Max  Nordau  also  insists  on  the  moral  disadvantages  of  the  wide 
diffusion  of  the  use  of  preventive  measures.  "  If  a  race  or  nation 
has  reached  this  point  in  its  downward  career,  the  individuals  of 
which  it  is  composed  lose  the  capacity  of  loving  in  a  healthy  and 
natural  manner.  The  sense  of  the  family  disappears;  the  men  will 
not  marry,  because  they  find  it  inconvenient  to  burden  themselves 
with  the  responsibility  for  another  human  life,  and  to  care  for  any 
other  creature  than  themselves;  the  women  dread  the  pains  and  in- 
conveniences of  motherhood,  and  if  they  marry,  they  endeavour, 


40O  THE  SEXUAL  LIFE  OF  WOMAN. 

by  the  employment  of  the  most  immoral  means,  to  ensure  barren- 
ness. The  reproductive  instinct,  of  which  reproduction  has  ceased 
to  be  the  aim,  is  in  some  annulled,  whilst  in  others  it  degenerates 
into  the  most  peculiar  and  irrational  perversities.  The  act  of  sexual 
union,  the  most  sublime  function  of  the  organism,  is  degraded  into 
a  profligate  act  of  lust ;  it  is  no  longer  undertaken  in  the  interest  of 
the  perpetuation  of  the  species,  but  exclusively  for  the  pleasure  of 
the  individual,  and  without  any  relation  to  the  needs  of  the 
community." 

Alfred  Russcl  Wallace  has  advocated  sexual  continence  as  a 
preventive  measure  during  the  period  of  maximum  vitality  and 
strength;  he  advises  that  the  age  of  marriage  of  women  should  be 
considerably  advanced,  in  order  to  diminish  their  fertility.  If 
woman's  average  age  at  marriage  were  29,  instead  of  20  years,  the 
fertility  of  marriages  would  be  reduced  in  the  ratio  of  8:5. 

The  desired  goal  of  artificial  sterility  will  not,  however,  be  reached 
through  the  advocacy  of  moderation  and  continence.  The  numerous 
additional  measures  employed  for  this  purpose  may  be  classified  as 
physiological  and  artificial;  the  latter  class  may  be  further  sub- 
divided into  mechanical  and  operative. 

By  physiological  means  for  the  prevention  of  conception,  we 
understand  measures  which  aim  at  producing  sterility  by  reducing 
the  number  of  acts  of  intercourse  and  by  restricting  these  acts  to 
certain  defined  periods  of  time.  The  physiological  preventive 
measures,  apart  from  the  higher  ethical  value  they  possess  in  com- 
parison with  artificial  measures,  have  the  advantage  that  they  may 
be  regarded  as  harmless  to  the  general  health  of  the  woman  and  to 
the  integrity  of  her  reproductive  organs  in  particular ;  they  have, 
however,  this  very  serious  disadvantage,  that  the  results  of  their  use 
are  very  uncertain,  so  that  they  offer  no  more  than  a  probability, 
and  often  a  very  moderate  probability  that  conception  will  be  pre- 
vented. 

As  a  physiological  measure  for  the  attainment  of  facultative  ster- 
ility "without  breaking  any  moral  law,"  Capcllmann  advised  ab- 
stinence from  coitus  during  a  period  of  fourteen  days  after  men- 
struation apd  three  to  four  days  before  the  commencement  of  the 
flow.  Without  laying  too  much  stress  on  the  fact  that  by  follow- 
ing this  recommendation  the  period  during  which  the  intercourse  is 
permissible  would  be  extremely  restricted,  it  is  necessary  to  point 
out  that,  whilst  in  this  way  the  occurrence  of  conception  may  be 
rendered  less  probable,  its  prevention  is  by  no  means  guaranteed, 


THE  SEXUAL  EPOCH  OF  THE  MENACME.  401  . 

for  it  is  an  established  fact  that  a  woman  may  be  impregnated  by 
intercourse  on  any  single  day  of  the  intermenstrual  interval.  Capcll- 
mann's  advice,  embodying,  -as  he  expresses  it,  the  "only  morally 
permissible "  means  for  the  prevention  of  conception,  was  not 
original,  for  the  same  recommendation  was  given  at  an  earlier  date 
by  Raciborski,  who,  however,  regarded  the  measure  as  very  un- 
certain. Capellmann  is  of  opinion  that  it  is  sufficiently  trustworthy 
for  practical  purposes. 

Bebcl,  who  is  a  declared  opponent  of  Malthusianism,  none  the 
less  lays  down  positive  rules  for  the  diminution  of  procreative 
capacity  and  of  fertility  by  regulation  of  the  diet.  He  refers  to  the 
example  of  the  bees,  which,  by  a  change  of  nutriment,  can  produce 
a  new  queen-bee  at  will.  "  Thus  the  bees,"  he  says,  "  are  in  ad- 
vance of  human  beings  in  their  knowledge  of  sexual  development. 
Presumably  they  have  not  been  compelled,  for  a  couple  of  thousand 
years,  to  listen  to  sermons  informing  them  that  to  occupy  them- 
selves about  sexual  matters  is  '  improper  '  and  '  immoral.'  There  is 
no  doubt  whatever  that  the  mode  of  nutrition  has  an  influence  on 
the  composition  of  the  male  semen,  and  also  on  the  susceptibility  to 
fertilization  of  the  female  ovum;  hence  the  increase  in  population 
must  to  a  very  important  extent  depend  on  the  mode  of  nutrition. 
If  this  could  be  definitely  established,  we  should  have,  in  the  supply 
of  nutriment,  a  means  of  regulating  the  population.  As  an  example 
of  the  effect,  in  this  connection,  of  the  mode  of  nutrition  in  the 
human  species,  it  is  reported  that  in  consequence  of  the  fatty  and 
nutritious  diet  of  the  old  Bavarian  peasants,  who  lived  chiefly  on 
very  rich  puddings,  the  marriages  of  the  well-to-do  peasants  were 
frequently  childless.  However,  it  must  not  be  forgotten  that  pre- 
conjugal  intercourse,  which  was  customary  in  that  part  of  the 
world,  and  was  somewhat  promiscuous  in  character,  may  have 
contributed  to  cause  this  sterility."  Finally,  Bcbel  points  out  that 
the  woman  of  the  future  "  will  be  unwilling  to  bear  a  large  number 
of  children.  She  will  wish  to  enjoy  a  measure  of  personal  freedom 
and  independence,  and  will  not  consent  to  pass  half  or  three-quar- 
ters of  the  best  years  of  her  life  either  pregnant,  or  with  a  child  at 
her  breast.  From  this  it  will  result  that  the  population  will  be 
regulated,  without  unwholesome  sexual  abstinence,  and  without  the 
employment  of  unpleasant  preventive  measures."  However,  Bcbel 
gives  us  no  details  as  to  the  precise  manner  in  which  this  regula- 
tion is  to  be  effected. 

Tolstoi,  in  his  widely  celebrated  book  "The  Kreuzer  Sonata," 

26 

_Ll£elE  Olr   OSTIEC 


i  \ 


402  THE  SEXUAL  LIFE  OF  WOMAN. 

condemns  absolutely  the  gratification  of  the  sexual  impulse.  He  de- 
mands the  recognition  of  the  fact  that  "  sexual  congress,  in  which 
a  man  either  avoids  the  natural  consequences  —  the  birth  of  chil- 
dren, —  or  else  throws  the  whole  burden  of  these  consequences  on 
the  woman,  is  opposed  to  the  simplest  demands  of  morality,  is  in  fact 
utterly  base."  To  render  possible  the  sexual  abstinence  he  regards 
as  morally  necessary,  men  must  not  only  endeavour  to  live  in  a 
natural  way,  but  they  must  consume  no  alcohol,  eat  with  great 
moderation,  abstain  from  meat,  and  not  be  afraid  of  hard  work. 
Tolstoi  even  demands  that  men  and  women  shall  be  so  brought  up 
"  that  both  before  and  after  marriage  they  may  regard  love,  and  the 
sensual  passion  associated  therewith,  not  as  they  do  at  present,  as  a 
sublime  and  poetical  state,  but  as  a  bestial  condition  degrading  to 
humanity."  Tolstoi  is,  however,  utterly  opposed  to  the  use  of  pre- 
ventive measures  :  "  first,  because  they  liberate  men  from  the  cares 
and  sorrows  entailed  by  having  children,  which  must  be  regarded  as 
the  penance  to  be  paid  for  sensual  love  ;  and,  secondly,  because  their 
use  is  closely  allied  to  the  crime  most  repugnant  to  the  human  con- 
science, the  crime  of  murder."  Chastity  is  no  less  a  duty  after 
marriage  than  before;  after  marriage  man  and  wife  must  "con- 
tinue to  pray  to  be  delivered  from  temptation,  and  must  endeavour 
to  replace  sensual  love  by  the  pure  relationship  of  brother  and 
sister." 

Enlenburg  regards  the  modern  diffusion  and  the  continuous  in- 
crease in  the  use  of  preventive  measures  as  signs  of  decadence  ; 
Lowenfeld,  on  the  other  hand,  regarding  the  social  conditions  of  the 
present  day  as  the  principal  source  of  the  use  of  preventive  meas- 
ures, sees  therein  no  moral  decay,  but  on  the  contrary  rather  a  rise 
in  the  moral  standard  of  life. 

Anothei  physiological  means  of  prevention  is  to  be  found  in 
avoiding  cohabitation  in  that  season  or  month  in  which,  judging  by 
the  woman's  previous  deliveries,  she  would  appear  to  have  been 
peculiarly  susceptible  to  impregnation.  Cohnstein  maintained  that 
in  woman,  as  in  the  lower  animals,  the  capacity  for  conception  was 
associated  with  a  particular  season  of  the  year,  that  there  was,  in 
fact,  an  individual  time  of  predilection  for  impregnation.  The 
assumption  that  there  is  such  a  time  of  predilection  is,  however, 
traversed  by  the  fact,  familiar  to  all  who  have  recorded  the  birth- 
days of  children  in  large  families,  that  these  occur  in  the  most 
diverse  months  of  the  year.  It  has,  indeed,  been  statistically  proved 
that  certain  months  and  seasons  are  especially  favourable  to  con- 
ception, that  a  maximum  of  conceptions  occurs  in  the  spring,  and 


fiU 


THE  SEXUAL  EPOCH  OF  THE  MENACME.  403 

a  second  much  smaller  maximum  in  the  winter ;  but  these  variations 
in  the  number  of  conceptions  depend  mainly  on  social  factors,  as, 
for  instance,  upon  the  customary  season  for  marriage,  opportunity 
for  intercourse  between  the  sexes,  common  labours  in  the  house  or 
in  the  open,  etc.  This  alleged  time  of  predilection  for  conception 
cannot,  therefore,  seriously  be  considered  in  the  discussion  of 
measures  for  the  prevention  of  pregnancy. 

As  a  physiological  means  for  preventing  conception,  passivity  of 
the  woman  during  sexual  intercourse  has  also  been  recommended. 
It  is  well  known  that  an  active  participation  on  the  part  of  the 
woman  in  the  sexual  act,  by  increasing  her  voluptuous  sensations, 
gives  rise  to  certain  reflex  actions,  viz.,  descent  of  the  uterus,  round- 
ing of  the  os  uteri,  induration  of  the  portio  vaginalis,  and,  finally, 
ejaculation  of  the  secretion  of  the  cervical  glands  and  of  the  glands 
of  Bartholin;  these  changes  accelerate  the  entrance  of  the  semen 
into  the  cavity  of  the  uterus,  and  increase  the  motility  of  the  sper- 
matozoa. Upon  this  fact  is  based  the  assumption,  that,  in  conse- 
quence of  deficient  sexual  excitement  during  intercourse,  either 
spontaneous,  or  when  the  woman  intentionally  remains  "  cold,"  the 
reflex  actions  by  which  the  upward  passage  of  the  spermatozoa  is 
favoured,  fail  to  occur ;  there  is  a  good  deal  of  evidence  in  favour 
of  the  truth  of  this  view.  Riedel  reports  regarding  the  women  of 
the  Island  of  Buru,  that  they  often  have  sexual  intercourse  with 
strange  men,  "  but  during  sexual  congress  in  such  cases  they  main- 
tain a  passive  and  indifferent  state,  for  the  purpose  of  avoiding 
impregnation."  Von  Krafft-Ebing  points  out  that  prostitutes,  when 
having  sexual  intercourse  with  men  to  whom  they  are  attached, 
experience  voluptuous  excitement,  whilst  in  intercourse  with  men 
to  whom  they  are  indifferent  they  remain  entirely  passive.  From 
this  it  would  appear  that  these  uterine  reflexes  are  under  the  do- 
minion of  the  conscious  will ;  but  sufficient  dependence  cannot  be 
placed  on  this  fact  in  all  circumstances  for  it  to  be  possible  to  em- 
ploy such  voluntary  control  as  a  trustworthy  means  of  prevention. 
Allied  to  this  is  previously-mentioned  Chinese  practice  of  Kong-fou, 
a  kind  of  hypnosis,  in  which  during  sexual  intercourse  the  thoughts 
are  concentrated  on  some  other  matter,  and  thereby  conception  is 
supposed  to  be  prevented. 

Artificial  protraction  of  the  period  of  lactation  is  an  old  and 
well-known  method,  practised  by  many  savage  peoples,  for  the 
prevention  of  fertilization.  As  a  general  rule,  as  long  as  lactation 
continues,  amenorrhoea  persists,  and  sexual  intercourse  remains 
unfruitful.  But  this  rule  also  is  not  universally  valid. 


404  THE  SEXUAL  LIFE  .OF  WOMAN. 

Artificial  means  for  the  attainment  of  facultative  sterility  are 
those  by  which  the  attempt  is  made  to  prevent  pregnancy  by  some 
mechanical  hindrance  to  the  contact  of  the  semen  with  the  ovum, 
since  without  this  contact  conception  cannot  possibly  occur. 

The  oldest  of  these  means  is  that  described  in  the  book  of  Genesis 
(ch.  xxxviii,  verses  9,  10),  congressus  interruptus,  where,  however, 
the  practice  was  punished  by  death,  "And  Onan  knew  that  the  seed 
should  not  be  his;  and  it  came  to  pass,'  when  he  went  in  unto  his 
brother's  wife,  that  he  spilled  it  on  the  ground,  lest  that  he  should 
give  seed  to  his  brother.  And  the  thing  which  he  did  displeased 
the  Lord,  wherefore  he  slew  him."  This  mode  of  preventing  preg- 
nancy, in  which  the  membrum  virile  is  completely  withdrawn  from 
the  vagina  before  the  ejaculation  of  the  semen  takes  place,  is  at 
the  present  time  a  very  widely  diffused  practice ;  and,  when  properly 
carried  out,  it  is  thoroughly  efficacious  in  the  production  of  sterility. 
Thompson  relates  that  this  practice  is  employed  by  the  Massai 
youths,  who  are  allowed  free  intercourse  with  the  girls,  but  if  a 
girl  becomes  pregnant  she  is  put  to  death. 

The  prolonged  practice  of  coitus  interruptus  leads  in  my  ex- 
perience—  in  addition  to  the  injury  to  the  nervous  system  as  a 
whole  in  consequence  of  the  intense  hyperaemia  of  the  uterus  and 
the  uterine  annexa,  unrelieved  by  the  occurrence  of  the  orgasm  — 
to  a  condition  of  stasis  in  the  female  reproductive  organs ;  and  this 
ultimately  passes  on  into  chronic  metritis  (with  relaxation  of  the 
uterus,  retroflexion  or  anteflexion,  cartarrhal  disease  of  the  mucous 
membrane,  erosions,  and  follicular  uloeration  of  the  portio  vaginalis), 
oophoritis  and  perimetritis.  As  a  result  of  certain  remarkable  obser- 
vations, I  must  even  regard  it  as  not  improbable,  although  actual 
proof  is  still  lacking,  that  the  recent  striking  increase  in  the  frequency 
of  neoplasmata  of  the  female  reproductive  organs  is  causally  de- 
pendent on  the  ever-increasing  employment  in  all  circles  of  society 
of  means  for  the  prevention  of  pregnancy. 

The  evil  effects  of  coitus  interruptus  for  a  woman  are  dependent 
on  the  fact  that  the  woman  fails  to  obtain  complete  sexual  gratifica- 
tion, and  that  this  has  an  important  influence  upon  her  entire 
organism.  Owing  to  the  failure  of  ejaculation  to  occur,  the  blood; 
which  during  the  stage  of  sexual  excitement  has  accumulated  in  the 
erectile  structures  and  cavernous  spaces  of  the  genital  passage,  does 
not,  as  in  normal  conditions,  flow  <-apidly  away ;  but  the  congestion 
persists  for  an  indefinite  period,  and  is  said  by  von  Krafft-Ebing 
to  give  rise  to  functional  disorders,  and  also  to  serious  tissue 


THE  SEXUAL  EPOCH  OF  THE  MENACME.  405 

changes.  The  functional  disorders  take  the  form  of  hypersemia  of 
the  pelvic  organs,  and  probably  also  of  the  lumbar  portion  of  the 
spinal  cord  (dull  pain  in  the  sacral  region,  a  sensation  of  pain  and 
dragging  in  the  pelvis  and  in  the  lower  extremities,  lassitude)  ;  these 
symptoms  often  continue  for  several  hours  after  intercourse.  If 
this  ungratifying  coitus  is  frequently  repeated,  in  a  voluptuous 
woman,  disorders  of  the  reproductive  organs  ensue ;  and  even  more 
frequently,  nervous  disorders,  in  the  form  of  neurasthenia  sexualis. 
This  author  considers  that,  more  especially  in  women,  coitus  in- 
terruptus,  and  unphysiological  modes  of  sexual  intercourse  in  gen- 
eral, are  extremely  potent  causes  of  sexual  neurasthenia  —  as  potent 
as  masturbation. 

Beard,  in  his  work  on  sexual  neurasthenia,  maintains  that  the 
sudden  interruption  of  coitus  (and  also  the  use  of  condoms  and 
similar  appliances)  is  not  only  far  more  deleterious  than  unduly 
frequent  normal  intercourse;  but  he  points  out  that  it  is  necessary 
also  to  take  into  account  the  fact  that  (inasmuch  as,  owing  to  the 
unnatural  mode  of  sexual  intercourse,  the  possibility  of  fertiliza- 
tion is  almost  completely  prevented)  sexual  intercourse  is  apt,  in 
such  cases,  to  be  indulged  in  far  more  frequently,  and  often  to  gross 
excess.  More  particularly  in  such  circumstances  are  evil  effects  on 
the  nervous  system  likely  to  ensue,  since  we  have  a  combination  of 
excessively  prolonged  and  frequent  sexual  intercourse,  and  of  in- 
terference with  complete  sexual  gratification. 

Mantegazza  believes  that  organic  diseases  of  the  spinal  cord  may 
actually  result  from  congressus  interruptus. 

Hirt  considers  that  even  when  marital  intercourse  is  carefully 
regulated  in  respect  of  frequency,  congressus  interruptus  may  lead 
to  neurasthenic  manifestations. 

Von  Hosslin  believes  it  to  be  indisputable  that  preventive  meth- 
ods of  sexual  intercourse  may  cause  nervous  troubles,  and  more 
particularly  neurasthenic  disorders,  manifesting  themselves  chiefly 
in  the  sphere  of  the  reproductive  organs. 

Eulenburg  also  declares  that  coitus  interruptus  is  already  a  fre- 
quent cause  of  sexual  neurasthenia  in  women,  and  that  its  evil 
influence  in  this  respect  is  becoming  more  and  more  frequently  mani- 
fest. He  publishes  two  typical  cases,  in  which,  from  this  cause,  in 
the  one  case,  functional  neuropathy,  and  in  the  other,  local  disorder 
of  the  reproductive  organs,  ensued. 

Freud  describes  an  "  anxiety-neurosis,"  which  is  due  to  incom- 
plete gratification  of  the  woman  during  sexual  intercourse.  Coitus 


406  THE  SEXUAL  LIFE  OF  WOMAN. 

interruptus  is  almost  invariably  harmful  to  the  man;  to  the  woman 
it  is  harmful  if  the  man  thinks  only  of  himself,  and  interrupts  the 
coitus  as  soon  as  ejaculation  is  imminent,  without  concerning  him- 
self about  the  woman's  state  of  sexual  excitement.  If,  on  the 
other  hand,  the  man  waits  until  the  woman's  sexual  gratification  is 
complete,  the  significance  of  such  an  interrupted  coitus  as  far  as 
the  woman  is  concerned  is  that  of  normal  intercourse. 

Isolated-  authorities,  as  for  instance  Stille  and  Thompson,  have 
contested  the  alleged  evil  consequences  of  preventive  methods  of 
sexual  intercourse.  "  It  is  habitual  excess,"  says  Fiirbringer,  "which 
does  the  mischief,  not  the  unnatural  character  of  the  isolated  act." 
Loivcnfeld,  who  considers  the  opposition  of  medical  men  to  "  Mal- 
thusianism  "  not  wholly  justified,  and  believes  that  the  dangers  to 
health  "  which  occur  in  isolated  cases  "  are  not  very  serious,  main- 
tains none  the  less  that  the  medical  man  must  advise  his  patients 
not  to  practise  coitus  interruptus.  The  mode  in  which  conception 
is  prevented  is  not,  he  thinks,  a  matter  of  indifference  to  the  woman. 
The  use  of  occlusive  pessaries  and  similar  appliances  does  not  in 
any  way  interfere  with  the  normal  development  of  sexual  gratifi- 
cation and  cannot,  therefore,  have  any  direct  influence  in  the  pro- 
duction of  nervous  disturbances.  A  forgotten  occlusive  pessary, 
however,  has  in  many  cases  caused  local  disorder  in  the  vagina. 
When  the  man  is  fully  potent  the  use  of  condoms  can  do  no  harm 
to  the  woman,  since  the  only  effect  of  the  condom  (in  a  very  ex- 
citable woman)  is  to  render  the  development  of  the  orgasm  a  little 
more  difficult,  but  not  to  prevent  it.  Congressus  interruptus  itself 
is,  according  to  Low  en  f  eld,  harmful  to  the  woman  only  when, 
owing  to  deficient  potency  in  the  male  or  to  deficient  excitability 
in  the  female,  the  interruption  takes  place  before  the  occurrence  of 
the  orgasm. 

Valenta  declared  that  coitus  interruptus  was  one  of  the  chief 
causes  of  chronic  metritis.  Elischer  saw  perimetritis  result  from 
this  practice;  Grdfe  enumerates,  as  consequences  of  frequently  re- 
peated coitus  interruptus,  chronic  hypersemia  of  the  uterus  and 
oophoritis;  Goodell  observed  elongation  of  the  cervix  uteri;  Men- 
singa,  infarction  of  the  uterus,  oedema  of  the  portio  vaginalis,  ulcera- 
tion  of  the  cervix,  hysterical  paroxysms,  convulsions,  cephalalgias, 
cardialgias,  etc.  Lier  reports  a  case  in  which,  after  three  years' 
continued  practice  of  coitus  interruptus,  the  menopause  set  in,  with 
atrophy  of  the  uterus ;  Ascher,  in  a  similar  case,  saw  chronic 
metritis  ensue.  According  to  Kleinwachter,  coitus  interruptus  is 


THE  SEXUAL  EPOCH  OF  THE  MENACME.  407 

harmful  to  the  woman  to  an  extent  by  no  means  trifling,  whereas 
the  man,  in  whom  ejaculation  occurs,  suffers  comparatively  little. 
Fehling  believes  that  when  coitus  interruptus  is  practised  only  a 
small  proportion  of  women  experience  sexual  excitement.  Neuge- 
bauer  states  that  among  the  very  numerous  cases  of  uterine  carci- 
noma he  has  treated,  the  majority  of  the  patients  admitted  having 
practised  coitus  interruptus.  Pigeolot  makes  a  similar  statement. 

It  must,  however,  be  admitted  that  a  certain  number  of  medical 
men  absolutely  deny  the  dangers  of  coitus  interruptus,  whilst  others 
consider  them  altogether  trifling.  Just  as  the  trend  of  modern 
opinion  is  to  believe  that  in  normal  men  and  women  the  dangers 
of  masturbation  are  far  less  serious  than  was  formerly  maintained, 
so  also  many  are  now  found  to  maintain  that  coitus  interruptus  is 
harmful  only  to  those  with  hereditary  neuropathic  predisposition. 
Still  more  unwilling  are  many  to  admit  that  other  preventive 
methods  do  women  any  harm.  Thus  Wille  maintains  that  the  con- 
tinued fear  of  pregnancy  will  in  most  instances  do  more  injury  to 
the  feminine  nervous  system  than  all  the  preventive  measures  in 
the  world.  To  the  nervously  weak  woman  a  trustworthy  preventive 
of  pregnancy  is  therefore  often  necessary  and  most  helpful. 

An  artificial  method  for  the  prevention  of  the  ejaculation  of 
semen  was  communicated  to  me  by  a  celebrated  anatomist.  It  is 
practised  in  Transylvania  and  in  France.  During  intercourse  the 
woman,  just  before  the  male  ejaculation  begins,  presses  forcibly 
with  her  finger  on  the  base  of  the  erect  penis  just  in  front  of 
the  prostate;  the  urethra  is  occluded  by  this  digital  compression, 
the  semen  regurgitates  into  the  bladder  and  is  subsequently  evacu- 
ated with  the  urine. 

This  practice  may  be  compared  with  the  mechanical  expulsion 
of  the  semen  from  the  female  genital  passage  immediately  after 
coitus.  Tairi  reports  that  women  of  the  poorer  classes  in  Italy 
sit  upright  in  bed  immediately  after  intercourse,  and  by  coughing, 
in  conjunction  with  pressure  on  the  abdomen,  effect  the  expulsion 
of  the  semen.  Morton  informs  us  that  the  native  women  of  North- 
ern Australia,  when  they  have  had  intercourse  with  a  white  man 
and  wish  to  avoid  impregnation,  likewise  deliberately  effect  the  out- 
flow of  the  semen  post  actum.  The  woman  squats  upright,  with 
the  legs  widely  separated,  and  by  a  sinuous  movement  of  the 
perineum  and  a  simultaneous  powerful  bearing-down  pressure  she 
expels  the  semen  on  to  the  ground. 

Another  way  in  which  the  attempt  is  made  to  avoid  impregnation 


408  THE  SEXUAL  LIFE  OF  WOMAN. 

is  by  the  use  of  vaginal  injections;  a  fluid  lethal  to  the  spermatozoa 
being  used  for  this  purpose  immediately  after  coitus.  Douches  of 
cold  water,  y2  to  i#  solution  of  copper  sulphate,  i$  solution  of  alum, 
y\%  solution  of  sulphate  of  quinine,  are  the  fluids  most  commonly 
employed ;  but  all  these  are  quite  untrustworthy,  for  it  is  impossible 
to  be  sure  that  all  the  spermatozoa  will  be  acted  on  and  destroyed. 
Allbutt,  who  as  medical  secretary  of  the  Malthusian  League  in 
London  has  unquestionably  had  a  very  wide  experience,  agrees 
with  Haussmann  in  denying  that  the  widely  advocated  cold  water 
douche  can  be  relied  on  for  the  prevention  of  pregnancy.  The  sud- 
den driving  of  the  blood  out  of  the  vessels  of  the  genital  passage 
at  the  very  moment  when  they  are  intensely  congested,  which  must 
inevitably  result  from  a  cold  douche,  is,  moreover,  likely  to  give 
rise  to  metritis,  perimetritis  and  oophoritis. 

More  trustworthy  are  the  various  apparatus,  the  aim  of  which 
is  to  prevent  the  contact  of  the  semen  with  the  ova  by  the  inter- 
position of  an  artificial  wall.  Although  even  as  regards  these  we 
must  bear  in  mind  the  observation  of  Lott,  who  found  that  sperma- 
tozoa were  capable  of  passing  through  the  intact  membrane  in 
favourable  regions  in  as  short  a  time  as  ten  minutes.  The  com- 
monest of  all  these  apparatus  is  the  article  known  as  a  condom, 
which  envelops  the  penis  with  a  membrane,  variously  consisting  of 
isinglass,  the  lamb's  caecum,  or  caoutchouc.  Condoms,  if  made  of 
suitable  material,  and  if  carefully  used,  are  the  most  trustworthy  of 
all  preventives.  Moreover,  the  injury  caused  by  their  use  to  the 
woman's  health  is  trifling,  for  they  do  no  more  than  diminish  to  a 
degree  the  intensity  of  the  stimulus,  thus  necessitating  a  somewhat 
longer  duration  of  its  action  in  order  to  effect  the  most  intense 
orgasm,  and  thus  to  induce  the  natural  physiological  termination 
of  the  nervous  excitement.  In  fact,  though  somewhat  delayed,  the 
normal  reaction  takes  place  in  the  reproductive  organs.  The  evil 
effect  of  the  use  of  the  condom  bears  no  comparison  with  that  of 
coitus  interruptus.  There  is,  however,  some  justification  for 
Ricord's  well-known  epigram,  that  the  condom  is  "  a  spider's  web 
for  the  prevention  of  danger,  and  a  cuirass  for  the  prevention  of 
voluptuous  pleasure." 

When  the  gynecologist,  from  well-considered  reasons  based  on 
some  pathological  condition  affecting  his  patient,  feels  justified  in 
recommending  the  prevention  of  pregnancy,  it  is  my  opinion  that 
the  most  trustworthy  and  least  harmful  measure  at  present  avail- 
able, and  one  preferable  to  all  other  mechanical  apparatus,  is  a  care- 
fully selected  and  well-made  condom. 


THE  SEXUAL  EPOCH  OF  THE  MENACME.  409 

The  condom  was  already  in  use  in  Italy  in  the  middle  of  the 
sixteenth  century,  in  the  form  of  a  linen  investment  adapted  to 
the  shape  of  the  penis;  subsequently,  according  to  Grunfeld,  con- 
doms were  made  from  the  caecum  of  the  lamb;  while  later  still, 
isinglass  was  employed  for  this  purpose.  According  to  Hans  Ferdy, 
the  caecal  condom  is  made  from  the  connective-tissue  layer  of  the 
caecum  of  the  sheep  or  of  the  calf  (a  very  young  animal)  ;  to 
a  less  extent,  also,  the  caeca  of  the  goat,  the  stag,  and  the  roe-deer, 
are  employed  for  this  purpose.  The  different  varieties  of  caecal 
condom  are  distinguished  chiefly  by  variations  in  the  thickness  and 
the  softness  of  the  membrane.  Ferdy  states  that  the  four  best 
kinds  are  made  from  the  caecum  of  the  sheep;  these  have  a  thick- 
ness: I.  0.008  to  o.oi  mm.  (0.00032  to  0.0004  m-)  >  H-  0.012  to 
0.015  mm.  (0.00048  to  0.0006  in.)  ;  III.  0.017  to  0.023  mm. 
(0.00068  to  0.00092  in.)  ;  IV.  0.025  to  0.03  mm.  (o.ooi  to 
0.0012  in.)  Next  in  quality  come  four  varieties  obtained  from  the 
calf,  varying  in  thickness  from  0.015  to  0.04  mm.  (0.006  to  0.016 
in.)  Finally  we  have  three  varieties  obtained  from  the  three  other 
animals  already  mentioned.  Thus  there  are  in  all  eleven  varieties  of 
caecal  condom,  and  in  so  far  as  during  the  process  of  manufacture 
the  membrane  has  remained  free  from  any  injury,  they  are  sold 
as  "  undamaged."  But  if  in  the  process  of  preparation  a  hole  has 
been  made  in  the  membrane,  this  aperture  is  closed  by  sticking  on  a 
small  patch  of  membrane.  Such  patched  condoms  are  naturally 
quite  useless,  since  the  patch  is  readily  loosened  by  the  moisture  to 
which  it  is  exposed,  and  falls  off,  when  the  protective  and  pre- 
ventive functions  are  entirely  destroyed ;  nevertheless,  such  de- 
fective condoms  are  often  sold.  Rubber  condoms,  continues  Ferdy, 
are  prepared  from  a  caoutchouc  membrane  0.03  to  o.i  mm.  (0.0012 
to  0.04  in.)  in  thickness;  but  these,  he  says,  are  not  hygienic,  for 
"  such  a  rubber  membrane,  which  both  in  the  man  and  in  the  woman 
completely  covers  the  erogenic  zones  normally  stimulated  in  coitus, 
deadens  the  necessary  stimulation,  so  that  the  sensations  during 
coitus  are  seriously  dulled  by  the  interposition  of  this  foreign 
body ;  by  nervously  predisposed  individuals,  this  kind  of  condom 
cannot  be  used  regularly  for  a  long  period,  without  rendering 
probable  the  onset  of  serious  functional  disturbances  of  the  genital 
apparatus."  This  opinion  appears  to  me  to  be  unfounded.  We  must 
also  mention  the  "  glans-condom,"  made  of  rubber  membrane, 
which  serves  to  cover  the  glans  penis  only  during  coitus,  and  to 
retain  the  seminal  secretion ;  its  grave  defect,  however,  consists  in 


4io  THE  SEXUAL  LIFE  OF  WOMAN. 

this,  that  in  the  act  of  withdrawing  the  penis,  the  condom  is  very 
likely  to  be  peeled  off,  when  the  semen  will,  after  all,  pass  into  the 
vagina. 

Passing  now  to  the  consideration  of  apparatus  which  are  in- 
serted into  the  woman's  genital  canal,  in  order  to  prevent  impregna- 
tion, we  may  first  mention  sponges,  which  have  long  been  in  use; 
after  thorough  cleaning,  these  may  be  rendered  aseptic  by  immer- 
sion in  carbolic  acid  or  lysol  solution.  These  sponges  should  be  very 
soft;  they  are  cut  into  balls  of  3  to  7  cm.  (1.2  to  2.8  in.)  in  diam- 
eter; before  coitus  they  are  introduced  into  the  vagina  and  after 
coitus  they  are  withdrawn  by  means  of  the  tape  which  should 
always  be  attached  to  them.  This  method  is,  however,  quite  un- 
trustworthy, for  the  sponge  offers  no  impermeable  wall  to  the 
passage  of  the  spermatozoa,  and  on  its  withdrawal,  some  of  the 
semen  may  very  likely  be  left  in  the  vagina.  The  same  objection 
must  be  made  to  the  similarly  constructed  anti-conceptional  cotton- 
wool plugs;  sometimes  these  are  moistened  with  a  fluid  intended 
to  destroy  the  spermatozoa.  Recently  Gunsburg  has  recommended 
the  introduction  into  the  vagina  of  a  cotton-wool  plug  moistened 
with  a  three  per  cent,  solution  of  carbolic  acid  in  glycerine ;  he  con- 
siders this  method  safe,  because  the  spermatozoa  are  immediately 
destroyed  on  contact  with  the  weakest  carbolic  acid  solutions. 

To  destroy  the  vitality  of  the  spermatozoa,  vaginal  suppositories 
made  of  cocoa-butter  medicated  with  hydrochlorate  of  quinine  have 
also  been  employed ;  these,  the  so-called  . "  security-pessaries  "  or 
"  security-ovals,"  are  inserted  into  the  vagina  half  an  hour  before 
coitus ;  the  cocoa-butter  is  melted  by  the  body  heat,  and  the  vaginal 
mucous  membrane  and  the  os  uteri  are  covered  with  the  medicated 
fatty  material,  by  which  the  spermatozoa  are  (or  should  be) 
destroyed.  This  method  is  one  easy  to  employ,  but  it  is  extremely 
uncertain. 

Even  more  uncertain  are  the  insufflators  charged  with  various 
powders  (boric  acid,  citric  acid,  thymol,  etc.);  the  tube  of. the 
insufflator  having  been  passed  into  the  vagina,  the  powder  is  blown 
over  the  vaginal  mucous  membrane  and  the  portio  vaginalis.  This 
procedure  may  sometimes  be  followed  by  symptoms  of  intoxication ; 
and  in  any  case,  owing  to  the  dessicative  effect  which  the  powder 
has  upon  the  vaginal  mucous  membrane,  it  exercises  a  disturbing 
influence  on  coitus. 

Kleinw'dchter,  in  cases  in  which  pregnancy  must  be  prevented  in 
the  interest  of  a  woman's  health  or  her  life,  has  recommended  the 


THE  SEXUAL  EPOCH  OF  THE  MENACME.  411 

introduction  into  the  vagina  of  globules  of  which  the  active  con- 
stituent is  boric  acid. 

A  rationally  constructed  apparatus,  and  one  which  in  general  ap- 
pears to  fulfil  its  purpose  very  well,  is  the  pcssarium  occlusivum 
constructed  by  Mensinga,  and  now  manufactured  in  various  modi- 
fications. The  occlusive  pessary  is  a  hollowed  hemisphere  of  rub- 
ber membrane,  around  the  margin  of  which  passes  a  steel  ring. 
The  size  of  the  pessary  must  be  adapted  to  the  individual  case. 
It  is  introduced  into  the  vagina  in  such  a  way  that  the  outer  sur- 
face of  the  hemisphere  occupies  the  vaginal  fornix,  while  the  steel 
ring  touches  the  vaginal  wall  all  round ;  by  this  means,  the  vaginal 
fornices  and  the  os  uteri  are  completely  shut  off  from  the  lower 
part  of  the  vagina.  The  disadvantage  of  this  instrument  is,  that 
either  the  woman  must  wear  it  continuously,  which  involves  numer- 
ous inconveniences,  or  else  it  must  be  introduced  by  the  skilled 
hand  immediately  before  coitus  —  and  not  every  woman  becomes 
competent  to  adjust  it  herself,  even  after  careful  explanation,  since 
the  pessary  must  be  accurately  placed  with  the  anterior  margin  of 
the  ring  immediately  behind  the  pubic  symphysis,  and  the  posterior 
margin  of  the  ring  behind  the  os  uteri.  Moreover,  the  instrument 
may  easily  be  displaced  by  violent  movements,  coughing,  sneezing, 
etc.  In  any  case,  the  pessary  must  be  carefully  selected  to  corre- 
spond within  the  configuration  of  the  vagina,  as  otherwise  it  may 
exercise  a  deleterious  pressure  upon  the  vaginal  walls,  and  may  give 
rise  to  other  bad  consequences,  such  as  are  apt  to  attend  the  wear- 
ing of  any  pessary  for  a  prolonged  period  — •  excoriations,  erosions, 
fluor  albus,  etc.  In  the  majority  of  cases  it  will  be  found  that  the 
woman  herself  is  not  competent  to  introduce  the  occlusive  pessary. 
The  skilled  hand  is  needed  for  the  proper  adjustment  of  the  sur- 
rounding ring. 

Gall's  balloon-occlusive-pessary  consists  of  a  soft  elastic  rubber 
disc,  surrounded  by  a  thin-walled  rubber  ring,  the  interior  of  which 
is  connected  by  means  of  a  fine  tube  with  an  inflating  rubber  ball. 
The  woman  can  herself  insert  the  instrument  and  inflate  the  ring; 
it  occludes  the  vaginal  passage  without  exercising  any  deleterious 
pressure. 

Other  pessaries  consist  of  hollow  rubber  balls  containing  some 
fluid  lethal  to  the  spermatozoa,  which  can  be  discharged  into  the 
vagina  on  opening  a  valve  by  pulling  a  string.  These,  however,  are 
as  insecure  as  the  above-mentioned  vaginal  discs  and  the  insufflators. 
The  duplex-occlusive-pessary  has  the  form  of  a  truncated  cone 


412  THE  SEXUAL  LIFE  OF  WOMAN. 

with  double  walls ;  in  its  base  are  a  number  of  rounded  apertures, 
and  a  single  elongated  aperture;  through  this  latter  a  boric  acid 
tablet  is  introduced  into  the  cavity  of  the  cone.  By  means  of  the 
cone  the  passage  to  the  uterus  is  mechanically  occluded;  the  semen 
passes  through  the  apertures  in  the  base  into  the  interior  of  the 
instrument,  and  as  the  boric  acid  tablet  is  dissolved  by  the  moisture 
to  which  it  is  now  exposed,  the  vitality  of  the  spermatozoa  is  de- 
stroyed. The  management  of  this  apparatus  is,  however,  not  easily 
effected  by  the  woman  herself.  The  "  Matrisalus-Pessary  "  differs 
but  little  from  other  occlusive  pessaries.  The  latest  instrument  for 
the  prevention  of  impregnation  is  known  as  the  "  Venus- Appar- 
atus ; "  it  consists  of  a  syringe  with  two  balls,  a  large  and  a  small 
one,  at  either  end  of  a  rubber  tube;  by  pressure  on  the  larger 
ball,  and  subsequent  relaxation  of  pressure,  the  smaller  ball  is 
filled  with  a  fluid  for  the  destruction  of  the  spermatozoa  (pre- 
pared by  the  solution  of  one  of  the  "  Venus-powders  "  sold  with 
the  instrument)  ;  when  filled,  this  smaller  ball  is  introduced  into 
the  vaginia  and  remains  connected  by  means  of  the  tube  with  the 
larger  ball,  which  lies  between  the  woman's  thighs.  At  the  moment 
of  the  male  ejaculation  the  woman  presses  on  this  ball,  and  by  this 
means  the  fluid  filling  the  smaller  ball  is  expressed  into  her  vagina. 
All  these  mechanical  occlusive  pessaries  are  open  to  the  objection 
that  they  are  apt  to  give  rise  to  irritative  conditions  of  the  genital 
organs,  causing  offensive  discharges,  pruritus,  etc.  (Recently  in 
order  to  diminish  this  drawback,  the  pessary  has  been  constructed 
of  vulcanized  cambric,  instead  of  rubber,  and  appears  then  to  have 
a  less  irritating  effect.)  Still  worse  is  the  injury  to  the  uterus  and 
to  the  cervical  mucous  membrane  caused  by  certain  intra-uterine 
instruments  which  have  been  recommended  for  the  prevention  of 
conception.  The  -latest  of  these  is  an  "  obturator,"  consisting  of  a 
silver  or  silver-gilt  tube,  which  is  passed  through  the  os  uteri  into 
the  interior  of  the  uterus,  and  left  in  situ.  It  is  claimed  for  it 
that  "  it  allows  the  menstrual  discharge  to  flow  freely  away,  but 
renders  the  entrance  of  the  spermatozoa  extremely  difficult."  Bier- 
mer  reports  five  cases  in  which  serious  injury  to  health  followed  the 
use  of  one  of  these  obturators.  In  one  of  these  cases  in  which 
there  were  very  severe  pains  and  a  discharge  from  the  uterus, 
Biermcr  removed  from  the  interior  of  the  uterus  a  broken  wing  of 
the  obturator;  the  patient  died,  however,  and  the  autopsy  disclosed 
perforation  of  the  uterus.  In  another  of  the  cases  the  apparatus 
was  also  broken. 


THE  SEXUAL  EPOCH  OF  THE  MENACME.  413 

Less  dangerous  is  the  recently  invented  tampon-speculum.  This 
is  passed  into  the  vagina  by  the  woman  herself,  in  order  that 
through  it  she  may,  by  means  of  a  special  introducer,  insert  a  tablet 
of  boric  acid,  hydrochlorate  of  quinine,  citric  acid,  or  some  other 
substance  lethal  to  the  spermatozoa.  Without  some  such  instrument, 
the  introduction  of  these  "  ovals  "  to  the  proper  place  is  often  found 
difficult  by  women. 

A  very  remarkable  means  of  bringing  about  artificial  sterility,  one 
resembling  the  operative  procedures  sometimes  adopted  in  western 
countries,  is  employed  in  various  parts  of  the  world,  and  notably  in 
the  East  Indies  and  in  the  Sunda  Islands,  namely,  the  induction  of 
an  artificial  malposition  of  the  uterus,  more  especially  of  anteversion. 
Thus,  van  dcr  Burg  writes  from  the  Dutch  Indies :  "  In  the  girls 
the  sexual  impulse  develops  very  early,  and  is  gratified  without  fear 
of  consequences,  when  the  services  of  certain  skilled  elderly  women 
have  been  requisitioned.  These  women  appear,  in  fact,  to  under- 
stand, by  means  of  pressure,  rubbing,  and  kneading,  through  the 
abdominal  walls  (not  by  the  vaginal  route),  how  to  induce  antever- 
sion or  retroversion  of  the  uterus,  to  such  an  extent  as  to  prevent 
the  occurrence  of  conception.  It  is  said  that  the  only  inconvenient 
consequences  of  this  procedure  are  trifling  pains  in  the  lumbo-sacral 
and  inguinal  regions,  and  some  trouble  in  passing  water  during  the 
first  few  days  after  the  manipulations  have  been  effected.  Later, 
when  a  girl  who  has  been  treated  in  this  way  wishes  to  marry  and 
become  a  mother,  by  a  reversal  of  the  manipulations  the  uterus 
is  restored  to  its  natural  position.  It  is  said  that  these  skilled 
women  have  been  called  in  by  European  women  in  the  Dutch  Indies, 
who  did  not  wish  to  have  many  children;  but  it  appears  that  in  a 
woman  who  has  once  given  birth  to  a  child,  the  result  of  the 
manipulations  is  less  to  be  depended  upon,  than  in  the  case  of  a 
virgin. 

A  means  of  ensuring  artificial  sterility,  which  in  all  civilized 
states  is  punishable  as  a  criminal  offence,  and  which  is  nevertheless 
very  frequently  practised,  is  the  artificial  induction  of  abortion. 
Especially  in  North  America  it  would  appear  that  there  exist  regu- 
lar professional  abortionists.  In  this  connection,  Thomas,  the  well- 
known  American  gynecologist,  writes  as  follows :  "  Statistics  show- 
ing the  frequency  of  criminal  abortion  are  not,  and  probably  never 
will  be,  available,  for  this  crime  cannot  be  adequately  controlled  by 
human  society,  and  commonly  eludes  legal  punishment.  It  seems 
a  hard  saying,  but  it  is  a  true  one,  to  assert,  that  the  law  pursues 


414  THE  SEXUAL  LIFE  OF  WOMAN. 

unremittingly  him  who  has  killed  his  fellow-man,  while  it  leaves 
immune  him  who  has  killed  the  embryo  in  the  mother's  womb.  On 
my  table  there  lies  at  this  moment  one  of  the  most  widely  circu- 
lated, most  respected,  and  most  carefully  edited  daily  newspapers  of 
New  York  —  a  paper  which  finds  its  way  into  the  best  circles  of 
society,  and  also  into  the  hands  of  girls  and  women  throughout 
the  country.  In  its  columns  I  find  fifteen  advertisements  which 
emanate  beyond  all  question  from  professional  abortionists — from 
men  and  women  who  gain  their  livelihood  by  child-murder." 

O.  Reyher  remarks  also  that  in  American  newspapers  advertise- 
ments such  as  the  following  are  of  every-day  occurrence :  "  Pills 
for  the  regulation  of  the  periods.  Ladies  expecting  to  be  con- 
fined are  warned  not  to  use  them  on  any  account,  for  if  they  do  so 
abortion  will  infallibly  ensue." 

Emmet,  in  his  "  Textbook  of  Gynecology  "  also  complains  of  the 
terrible  frequency  of  criminal  abortion,  so  that  "  every  day  we  see 
more  unhappiness  and  misery  result  from  the  misuse  of  conjugal 
relationships  than  we  see  in  an  entire  month  as  a  result  of  births 
which  take  place  in  a  natural  manner." 

Pomerey  also  says  that  "  The  prevention  of  conception  and  the 
destruction  of  the  unborn  life  are  pre-eminently  American  sins;" 
and  he  adds  that  if  no  bounds  are  set  to  their  spread,  "  they  must, 
sooner  or  later,  lead  to  universal  misfortune.  In  the  course  of  our 
practices  we  come  into  contact  with  women  who  would  hesitate  to 
kill  a  fly,  but  who  think  nothing  of  having  destroyed  half  a  dozen 
or  more  of  their  own  unborn  children." 

The  American  Medical  Congress  offered  a  prize  for  a  brief  and 
readable  essay,  suitable  for  diffusion  among  women,  showing  the 
criminality  and  the  physical  harmfulness  of  artificial  abortion.  The 
prize  was  awarded  to  Storer's  essay,  entitled  "Why  Not?" 

Among  the  ancient  Greeks,  the  fear  of  over-population  led  to  the 
practice  of  homosexual  intercourse.  The  states  of  ancient  Greece 
were  in  most  cases  of  a  very  small  area,  so  that  a  very  moderate 
increase  in  population  would  render  the  means  of  subsistence  in- 
sufficient. Hence  intercourse  with  women  was  avoided,  and  the 
sexual  impulse  was  gratified  in  unnatural  ways.  Inspired  by  this 
fear  of  over-population,  Aristotle  urged  upon  men  that  they  avoid 
women,  and  should  indulge  in  the  love  of  men  and  boys,  and  at 
an  earlier  date,  Socrates  had  celebrated  the  love  of  boys  as  a 
mark  of  higher  culture.  The  most  notable  men  of  classical  Greece 
practised  homosexual  intercourse;  authors  and  poets  celebrated  the 
love  of  boys.  Stimulated  by  their  example,  Sappho  of  Lesbos  be- 


THE  SEXUAL  EPOCH  OF  THE  MENACME.  415 

came  the  inspired  poetess  of  the  love  of  women  for  members  of 
their  own  sex  (Lesbian  love). 

Among  the  Romans  it  was  rather  satiety  in  consequence  of  sex- 
ual excesses  which  led  in  that  country  to  the  diffusion  of  the  Greek 
love  of  boys ;  the  consequent  childlessness  diminished  to  such  an 
extent  the  numbers  of  the  Roman  burghers  and  patricians,  that 
Augustus,  in  the  year  16  B.  C,  enacted  the  Julian  law,  by  which 
the  procreation  of  children  was  rewarded,  whilst  celibacy  became 
a  punishable  offence. 

At  the  present  day  the  fear  of  an  excessively  large  number  of 
children,  in  relation  to  the  property  possessed  by  the  parents  and  in 
regard  to  nutritive  possibilities,  has  led  among  whole  classes,  and 
even  among  entire  nations,  to  the  adoption  of  preventive  measures 
in  sexual  intercourse ;  these  measures  have,  in  fact,  been  developed 
into  a  system,  which  finds  adherents  among  all  strata  of  the  popu- 
lation, but  more  especially,  as  it  is  easy  to  understand,  among  cer- 
tain well-to-do  sections  of  the  community.  In  France  this  system 
has  been  adopted  to  such  an  extent  as  to  amount  to  a  national 
calamity. 

In  few  countries  of  the  civilized  world,  remarks  Bebel,  are  mar- 
riages so  frequent,  relatively  to  the  population,  as  they  are  in 
France,  whilst  in  no  country  is  the  average  number  of  children  per 
marriage  so  small,  or  the  increase  of  population  so  slow.  The 
French  bourgeoisie  long  ago  adopted  this  system,  and  the  peasantry 
and  the  artizan  classes  are  following  their  example.  In  many  parts 
of  Germany  the  same  causes  have  led  to  the  same  results.  In 
France,  in  addition  to  the  prevention  of  pregnancy  and  the  practice 
of  artificial  abortion,  infanticide  and  the  exposure  of  children  are 
also  actually  employed  to  keep  down  the  population. 

Operative  measures  for  the  production  of  artificial  sterility  have 
been  practised  from  very  ancient  times,  and  by  civilized  and  savage 
peoples  alike.  According  to  Strabo,  the  ancient  Egyptians  and 
Lydians  were  acquainted  with  the  art  of  removing  the  ovaries  from 
girls  and  women.  The  kings  of  Lydia,  Andromytes  and  Gyges, 
had  the  women  of  their  harems  castrated,  ut  us  semper  cctate  et 
forma  florentibus  uteretur.  Von  Micklucho-Mackay  reports  that  in 
some  parts  of  Australia  the  indigens  remove  the  ovaries  of  certain 
girls,  in  order  to  provide  their  young  men  with  hetairae  who  cannot 
possibly  become  pregnant.  M.  Gillirray  saw  at  Cape  York  a  native 
deaf  and  dumb  woman  whose  ovaries  had  been  removed,  to  pre- 
vent her  procreating  deaf  and  dumb  infants. 


416  THE  SEXUAL  LIFE  OF  WOMAN. 

We  cannot  refrain  from  reference  to  the  astounding  proposal 
of  C.  A.  Weinhold,  contained  in  his  work  upon  the  over-population 
of  Central  Europe  and  its  consequences  to  the  countries  concerned 
and  to  civilization  in  general.  He  advises,  "  as  a  general  and 
urgently  required  measure,  the  widespread  practice  of  a  sort  of  in- 
fibulation,  which  is  to  be  undertaken  at  the  age  of  fourteen  and 
preserved  until  marriage,  and  is  to  be  performed  in  the  case  of 
all  those  individuals  who  can  be  proved  not  to  possess  sufficient 
property  for  the  upbringing  of  an  infant,  if  they  should  become 
pregnant  as  a  result  of  extra-conjugal  intercourse.  And  in  those 
who  never  attained  a  financial  position  in  which  they  might  be  able 
to  bring  up  a  family,  the  infibulated  condition  should  be  allowed 
to  persist  throughout  life!" 

This  proposal  is,  in  fact,  no  novelty,  inasmuch  as  the  bringing 
about  of  an  artificial  adhesion  of  the  labia  with  a  view  to  the 
prevention  of  conception  —  the  operation  of  infibulation  —  is  prac- 
tised by  many  savage  peoples.  According  to  the  detailed  account 
given  by  Ploss-Bartcls,  this  operation,  in  which  the  inner  surfaces 
of  the  labia  majora  are  freshened,  stitched  together,  and  allowed  to 
adhere,  is  practised  by  the  Bedschas,  the  Gallas,  the  Somalis,  the 
inhabitants  of  Harrar,  at  Massaua,  etc.  The  purpose  of  this  prac- 
tice is  to  preserve  the  chastity  of  the  girls  until  marriage,  when  the 
reverse  operative  procedure  is  undertaken.  If  the  husband  goes 
away  on  a  journey,  in  many  cases  the  operation  of  infibulation  is 
once  more  performed  upon  his  wives.  Slave-dealers  also  make  use 
of  this  operation  so  as  to  prevent  their  slaves  from  becoming  preg- 
nant. It  is  reported,  however,  that  the  operation  does  not  invariably 
produce  the  desired  effect.  Hartmann  informs  us  that  in  Nubia,  in 
Senaar,  and  in  part  of  Kordofan,  the  prseputium  clitoridis  or  the 
entire  clitoris  is  cut  away,  and  the  margins  of  the  nymphse  are  then 
freshened  and  stitched  together,  so  that  the  only  aperture  left  is 
one  sufficiently  large  for  the  outflow  of  the  urine. 

Brchm  states  that  the  operation  is  performed  by  old  women,  who 
make  the  necessary  incisions  with  razors;  shortly  before  marriage, 
the  bridegroom  sends  the  girl's  relatives  a  model  of  his  penis,  carved 
in  wood,  according  to  the  size  of  which  an  aperture  is  made  between 
the  adherent  nymphse;  when  the  woman  becomes  pregnant,  the  in- 
cision is  still  further  .enlarged.  In  the  king-dom  of  Darfur.  the 
labia  majora  as  well  as  the  nymphae  are  freshened  and  stitched 
together.  In  the  Berber  country,  Werne  became  acquainted  with  a 
young  widow  whose  husband  had  had  her  submitted  to  the  opera- 


THE  SEXUAL  EPOCH  OF  THE  MENACME.  417 

tion  of  infibulation  no  less  than  seven  times.  Another  somewhat 
less  brutal  method  of  performing  infibulation  is  described  by  Ploss, 
as  being  practised  by  many  Eastern  races ;  a  ring  is  fastened  through 
the  labia  in  such  a  way  as  to  guard  the  introitus  vaginas.  In  Eu- 
rope, during  the  Middle  Ages,  such  and  similar  apparatus  ("  girdles 
of  chastity")  are  said  to  have  been  employed  for  the  protection  of 
the  honour  of  an  absent  husband. 

Of  gynecologists  who  have  advised  operative  measures  for  the 
prevention  of  pregnancy,  in  women  in  whom  that  condition  involved 
serious  dangers,  the  first,  as  far  as  I  know,  was  Blundell.  As  a 
result  of  experiments  made  on  rabbits,  he  suggested  division  of  the 
Fallopian  tubes  as  the  best  way  of  attaining  this  end.  Later,  Fror- 
iep  and  Kocks  also  endeavoured  to  induce  artificial  sterility  in  wo- 
men by  occlusion  of  the  Fallopian  tubes.  Froriep's  idea  was  to  bring 
about  obliteration  of  the  lumen  of  the  tubes  by  means  of  cauteriza- 
tion with  nitrate  of  silver ;  Kocks  constructed  for  the  same  purpose 
a  galvano-caustic  uterine  sound.  But,  in  the  first  place,  both  the 
methods  advocated  are  too  uncertain  to  be  relied  upon;  and,  in  the 
second  place,  their  application  is  neither  easy,  nor  devoid  of  serious 
risk. 

Much  more  effective,  however,  is  the  method  recommended  by 
Kchrer  for  the  sterilization  of  women,  namely,  division  of  the 
Fallopian  tubes  by  the  vaginal  route.  Kehrer  considers  that  the 
physician  is  justified  in  preventing  the  occurrence  of  pregnancy  in 
a  number  of  morbid  conditions  — •  incurable  nervous,  cardiac,  pul- 
monary, gastric,  and  renal  disorders ;  various  constitutional  affec- 
tions ;  and,  finally,  in  cases  of  pelvic  deformity  of  such  a  degree 
that  the  delivery  of  a  living  child  is  impossible  except  by  means 
of  Csesarean  section,  but  the  patient  does  not  wish  to  be  exposed 
to  the  risks  of  this  operation.  He  believes,  moreover,  that  all  the 
methods  commonly  recommended  for  the  prevention  of  pregnancy 
are  untrustworthy.  So  powerful,  however,  is  the  sexual  impulse, 
that,  as  experience  shows,  the  mere  prohibition  of  sexual  inter- 
course, however  earnestly  made,  invariably  proves  ineffectual.  For 
coitus  interruptus  to  be  effective,  the  interruption  must  occur  at 
the  right  moment ;  and  this  does  not  always  take  place.  Cold  water 
douches  after  coitus  are  unhygienic ;  douches  of  warm  water,  medi- 
cated with  sublimate,  alcohol,  and  other  drugs  lethal  to  the  sperma- 
tozoa, are  indeed  rationally  conceived,  but  often  fail  of  their  effect, 
either  because  they  are  deferred  until  too  late,  or  else  because  they 
fail  to  irrigate  all  parts  of  the  vagina.  Plugs  of  cotton  wool, 

27 


418  THE  SEXUAL  LIFE  OF  WOMAN. 

sponges,  etc.,  are  not  always  introduced  in  such  a  way  as  effectually 
to  occlude  the  vaginal  passage.  A  suitable  and  properly  introduced 
occlusive  pessary  is,  indeed,  a  relatively  trustworthy  preventive 
apparatus,  but  if  worn  continuously  it  is  apt  to  become  very  foul.  A 
thorough  douching  of  the  genital  passage  with  an  antiseptic  solu- 
tion, performed  by  the  skilled  hand,  immediately  after  coitus, 
would  doubtless  destroy  the  spermatozoa  with  the  like  certainty 
with  which  the  same  procedure  destroys  micro-organisms  when 
performed  prior  to  a  gynecological  operation  —  but  when  carried 
out  by  the  layman,  the  value  of  the  method  is  more  than  doubtful. 
The  operation,  for  a  time  actually  fashionable,  of  extirpation  of 
the  uterine  annexa,  certainly  gives  rise  to  sterility,  but  entails  the 
serious  disadvantage  that  the  consequent  premature  menopause  is 
attended  by  the  same  disturbances  as  the  natural  change  of  life. 
On  the  other  hand,  section  and  ligature  of  the  Fallopian  tubes  is 
considered  by  Kehrcr  to  induce  sterility  without  in  any  other  way 
disturbing  the  functions  of  the  female  reproductive  organs.  By  means 
of  anterior  colpotomy  we  obtain  a  suitable  route  for  the  ligature  and 
section  of  both  tubes  at  the  isthmi.  When  carried  out  with  the 
proper  antiseptic  precautions  the  operation  is  almost  entirely  free 
from  risk;  and  when  the  organs  are  healthy  the  closure  of  both 
the  upper  and  the  lower  segments  of  the  tubes  is  effected,  and  no 
retention  of  secretions  need  be  feared  as  a  result  of  the  operation. 

With  regard  to  the  indications  for  the  performance  of  this  opera- 
tion, Kehrer  insists  that  it  should  be  undertaken  only  in  cases  of 
serious  disease,  and  when  the  pros  and  cons  have  been  conscien- 
tiously weighed.  A  consultation  is  also  indispensable.  Moreover,  it 
is  essential  that  husband  and  wife  should  both  fully  understand 
the  nature  of  the  proposed  operation,  and  should  form  an  unbiassed 
judgment  regarding  its  advisability.  To  avoid  any  possibility  of 
subsequent  reproaches,  Kehrer  advises  that  a  written  report  should 
be  drawn  up,  giving  the  reasons  for  undertaking  the  sterilization, 
and  that  this  should  be  subscribed  by  the  physicians  in  consultation, 
by  the  patient  herself,  and  by  her  husband. 

Arendt  considers  that  in  cases  in  which  there  already  exists  seri- 
ous constitutional  disease,  the  performance  of  this  operation  may 
lead  to  fever,  severe  haemorrhage,  injury  to  adjacent  organs,  and 
even  death.  He  holds,  therefore,  that  in  such  cases  the  physician 
should  advise  the  use  of  some  of  the  more  ordinary  methods  of 
preventing  conception  (if  simple  abstinence  from  intercourse  can- 
not be  practised).  Only  in  women  with  pelvic  contraction  of  the 


THE  SEXUAL  EPOCH  OF  THE  MENACME.  419 

second  or  third  degree,  in  whom  previous  children  have  been  still- 
born, or  subjected  to  craniotomy,  is  operative  sterilization  by 
Kchrcr's  method  justifiable.  But  in  preference  to  anterior  colpotomy, 
as  recommended  by  Kehrer,  he  prefers  the  longitudinal  incision  in 
the  posterior  vaginal  fornix  advised  by  Boileux.  If  the  uterus  is 
drawn  down  firmly,  and  the  portio  vaginalis  then  pushed  forward 
against  the  pubic  symphysis,  it  is  easy,  at  any  rate  with  the  assistance 
of  a  little  abdominal  pressure,  to  draw  part  of  the  Fallopian  tubes 
into  the  vaginal  incision. 

Recently  P incus  has  recommended  the  cauterization  of  the  uterine 
cavity  with  superheated  steam  (atmocausis,  castratio  uterina).  He 
advises  it  only  in  women  who  are  incurably  ill  (tuberculosis,  morbus 
Brightii,  haemophilia),  so  that  pregnancy  and  parturition  would 
involve  almost  certain  death. 

Kossniann  considers  that  when  pregnancy  and  parturition  will 
endanger  a  woman's  health  and  life,  it  is  the  physician's  duty  to 
acquaint  both  husband  and  wife  with  this  fact;  but  having  done 
so  his  duty  is  fully  discharged.  "  If,  after  being  warned,  the  mar- 
ried pair  choose  to  indulge  in  sexual  intercourse,  they  have  know- 
ingly and 'voluntarily  run  into  danger,  and  for  this  the  physician  is 
in  no  way  responsible." 

As  indications  for  facultative  sterility  Levy  enumerates  tubercular 
disease  of  the  lungs,  mental  disorders,  severe  organic  or  functional 
diseases  of  the  central  nervous  system,  active  syphilis  (in  certain 
circumstances),  pernicious  anaemia,  haemophilia,  diabetes  mellitus, 
severe  heart  disease,  chronic  disease  of  the  kidneys  or  liver,  certain 
pelvic  deformities,  and  the  tendency  to  habitual  abortion. 

I  have  myself  before  now  stated  my  opinion  that  it  is  the  duty 
of  the  physician,  in  the  case  of  a  married  woman  suffering  from 
heart  disease,  with  due  regard  to  the  danger  which  pregnancy  will 
entail  upon  her,  to  give  needful  advice  in  the  matter  of  the  pre- 
vention of  conception.  In  women  affected  with  valvular  heart 
disease,  and  in  whom  there  are  serious  disturbances  of  compensa- 
tion, conception  is  absolutely  to  be  avoided;  also  in  conditions  of 
marked  cardiac  degeneration,  and  when  there  are  distinct  symptoms 
of  insufficiency  of  the  heart  muscle.  When,  on  slight  exertion, 
palpitation,  increased  frequency  of  the  pulse,  and  respiratory  need 
("  air-hunger "),  ensue;  when  there  is  extensive  oedema  of  the 
lower  extremities  which  persists  even  after  confinement  to  bed ; 
when  the  pulse  readily  becomes  arhythmical  both  in  respect  of  the 
strength  and  the  temporal  succession  of  the  beats;  when  the  urine 


420  THE  SEXUAL  LIFE  OF  WOMAN. 

is  scanty  and  contains  varying  quantities  of  albumen;  when  there 
are  frequent  attacks  of  heart- weakness,  with  a  small  irregular 
pulse,  coldness  of  the  extremities,  a  cyanotic  tint  of  complexion, 
nausea,  dyspnoea,  sense  of  faintness,  or  actual  syncope  —  in  all  such 
cases,  whether  dependent  upon  valvular  disease,  on  pathological 
changes  in  the  arteries,  or  upon  disease  of  the  myocardium,  the 
occurrence  of  pregnancy  is  a  true  disaster,  giving  rise  in  most 
cases  to  a  grave  aggravation  of  the  heart  trouble  and  often  enough 
costing  the  patient  her  life.  I  further  regard  it  as  a  sound  medical 
axiom  that  in  cases  of  cardiac  disorder  of  a  less  severe  type  than 
that  just  described  the  woman  thus  affected  should  not  have  more 
than  one  or  two  children.  This  is  the  more  necessary  because  with 
each  successive  pregnancy  the  functional  capacity  of  the  diseased 
heart  decreases  in  geometrical  progression  and  the  danger  to  life 
proportionately  increases.  But  in  such  cases  of  heart  disease  the 
prevention  of  pregnancy  must  never  be  effected  by  the  interruption 
of  coitus  by  the  man  before  ejaculation,  for  the  reason  that  this 
procedure  gives  rise  to  manifold  reflex  cardiac  troubles,  and 
especially  to  paroxysms  of  tachycardia,  with  simultaneous  diminu- 
tion in  vascular  tone,  vasomotor  disturbances,  and  states  of  mental 
depression  —  and  these  entail  exceptional  dangers  in  women  suffer- 
ing from  heart  disease. 

THE  DETERMINATION  OF  SEX. 

The  problem  of  the  determination  of  sex  in  the  human  species 
is  one  which  has  occupied  natural  philosophers  from  the  very 
earliest  times,  and  has  always  greatly  interested  all  classes  of  the 
population. 

The  interest  awakened  by  the  subject  depends  principally  on  the 
fact  that  female  children  have  usually  been  less  desired  than  male 
in  all  periods  of  history  and  among  almost  all  races.  In  the  upper- 
most circles  of  society  the  truth  of  this  statement  is  manifested  by 
the  fact  that  the  birth  of  a  prince  is  announced  by  a  salute  of  101 
guns,  that  of  a  princess  by  a  salute  of  35  guns  only. 

It  would  serve  no  useful  purpose  to  transcribe  here  the  opinions, 
or  rather  guesses,  which  were  ventured  on  this  topic  in  earlier 
days  when  the  very  nature  of  the  reproductive  process  was  still 
entirely  unknown,  and  we  shall  merely  mention  that  the  curious 
will  find  various  references  to  the  determination  of  sex  in  the  works 
of  Hippocrates,  Aristotle,  Plutarch,  Soranus,  Susruta  and  Galen. 


THE  SEXUAL  EPOCH  OF  THE  MENACME.  421 

Broadly  speaking,  the  earlier  theories  may  be  said  to  diverge  in 
two  main  directions,  some  holding  that  the  sex  of  the  infant  was 
in  some  way  determined  by  the  mode  of  intermixture  of  the  male 
and  the  female  elements  in  the  act  of  generation,  and  others  main- 
taining that  sex  was  already  inalterably  predetermined  at  the  time 
of  intercourse  either  in  the  male  or  in  the  female  sexual  elements. 

Par  I  passu  with  the  modern  development  of  the  theory  of  evolu- 
tion, and  with  the  enormous  increase  in  recent  days  in  anatomical 
and  physiological  knowledge,  the  theory  of  the  determination  of 
sex  has  been  very  widely  extended.  The  rival  views  may  be  briefly 
arranged  in  the  four  following  categories: 

I.  That  sex  is  already  inalterably  predetermined  in  the  ovum, 
upon  the  constitution  of  which  it  solely  depends;  there  are  there- 
fore male  and  female  ova,  and  the  process  of  fertilization  exercises 
no  influence  whatever  upon  the  determination  of  sex.     The  alterna- 
tive theory  to  the  above,  that  sex  is  determined  solely  by  the  con- 
stitution of  the  fertilizing  spermatozoon  —  i.  e.,  that  the  spermato- 
zoa, and  not  the  ova,  are  male  and  female,  respectively  —  is  one 
which  in  recent  years  has  tended  more  and  more  to  disappear  from 
the  field. 

II.  That  sex  is  determined  in  the  moment  of  fertilization  by  the 
reciprocal  interaction  of  male  and  female,  of  zoosperm  and  ovum. 
One  variant  of  this  theory  maintains  that  each  reproductive  ele- 
ment strives  for  the  reproduction  of  its  own  sex;  that  a  struggle 
takes  place  and  that  the  victor  in  the  contest  stamps  its  own  sex- 
likeness  upon  the  fertilized  product.     According  to  another  view, 
however,  sex  is  not  directly  transmitted  in  this  manner;  it  is  sup- 
posed  that   the   more   powerful   the   proper   reproductive   element 
(according  to  this  theory  the  ovum)  the  more  strongly  does  it  tend 
to  determine  the  reproduction  of  a  stronger,  i.  e.,  a  male  organ- 
ism ;  thus  the  greater  potency  of  the  female  element  in  the  act  of 
reproduction  tends  to  favour  the  determination  of  the  male  sex. 

III.  That  sex  is  not  determined  until  after  fertilization,  during1 
the  early  stages  of  the  development  of  the  embryo ;  the  determining" 
causes  are  supposed  to  be  various  factors  capable  of  influencing1 
the  developing  organism  during  this  period,  and  more  particularly 
the  nutritive  conditions  of  the  mother. 

IV.  That  the  determination  of  sex  is  not  dependent  solely  upon 
the  action  of  any  single  one  of  the  factors  above  enumerated,  but 
arises  as  a  resultant  effect  of  the  operation  on  the  germ  of  all  three 
of  these  acting  in  temporal  succession. 


422  THE  SEXUAL  LIFE  OF  \\  UMAX. 

Modern  physiology  has  endeavoured  to  solve  this  problem  by 
statistical  investigations,  by  anatomical  demonstration,  and  finally 
by  experiment. 

/.     Statistical  Investigations. 

Statistical  data  have  been  collected  showing  the  ratios  between 
male  and  female  births  in  the  most  varied  conditions  possible,  and 
from  these  data  the  attempt  has  been  made  to  draw  valid  conclu- 
sions regarding  the  causes  of  the  determination  of  sex.  'Now  in 
the  first  place  it  is  above  all  necessary  to  bear  in  mind  that  such 
statistical  data  cannot  possibly  have  any  value  unless  they  relate 
to  very  numerous  instances,  and  even  then  they  are  liable  to  be 
invalidated  by  various  sources  of  fallacy.  We  may  with  advantage 
quote  in  this  connection  the  remarks  of  Hcnscn  in  his  work  on  the 
"  Physiology  of  Reproduction :"  "  Each  individual  instance  is  ren- 
dered unique  in  kind  by  the  interaction  of  certain  incommensurable 
elements;  for  instance  the  state  of  health  of  the  individual  organs 
in  their  innumerable  combinations,  variations  in  the  general  health 
of  the  parents,  the  frequency  of  coitus  and  the  time  at  which  it 
took  place,  the  desire  of  the  parents  to  have  a  son  and  then  no 
more  children,  their  social  position  —  in  these  ways  innumerable 
complications  are  introduced  into  the  problem,  and  the  difficulty  of 
drawing  valid  conclusions  is  rendered  almost  insuperable,  unless 
the  number  of  instances  dealt  with  is  enormously  large." 

One  fact  definitely  established  is  that  more  boys  are  born  than 
girls,  the  proportion  between  the  two,  known  as  the  sexual  ratio, 
being  106:100.  Statistics  relating  to  the  half  of  Europe  (Ocstcrlcn) 
and  dealing  with  59,350,000  births,  showed  a  ratio  of  106.3  male  to 
100  female  births;  in  individual  countries  variations  from  this  mean 
are  found  to  occur,  but  these  are  not  very  extensive,  the  highest 
ratio  being  107.2:100,  and  the  lowest  ratio  105.2:100. 

From  the  works  of  Hof acker  ("  Ueber  die  Eigenschaften  welche 
sich  bei  Menschen  und  Tieren  von  den  Eltern  auf  die  Nachkommen 
vererben  " —  Concerning  the  Qualities  transmitted  from  Parents 
to  Offspring  in  Men  and  Animals  —  Tuebingen,  1828)  and  Sadler 
("Law  of  Population,"  London,  1830)  conclusions  have  been  drawn 
regarding  the  effect  of  a  variation  in  the  age  ratio  of  the  parents 
on  the  determination  of  sex.  The  deductions  in  question,  known  as 
PI  of  acker  and  Sadler's  law,  are  as  follows: 

i.  If  the  husband  is  older  than  the  wife  more  boys  are  born  than 
girls. 


THE  SEXUAL  EPOCH  OF  THE  MENACME.  423 

2.  If  husband  and  wife  are  the  same  age  somewhat  fewer  boys 
are  born  than  girls. 

3.  If  the  wife  is  older  than  the  husband  the  excess  of  female 
births  is  larger  still. 

Ho j 'acker's  actual  figures  were  the  following: 

Father  younger  than  mother 90.1  boys  to  100  girls. 

Father  same  age  as  mother 93.3  boys  to  100  girls. 

Father  4  to  6  years  older  than  mother 108.8  boys  to  100  girls. 

Father  6  to  9  years  older  than  mother 124.7  boys  to  100  girls. 

Father  9  to  12  years  older  than  mother.  ...  143.7  boys  to  100  girls. 


Sadler's  results  were  closely  similar : 

Father  younger  than  mother 86  boys  to  too  girls. 

Father  same  age  as  mother 94  boys  to  100  girls. 

Father  i  to  6  years  older  than  mother 103  boys  to  100  girls. 

Father  6  to  n  years  older  than  mother.  ...  126  boys  to  100  girls. 

Father  n  to  16  years  older  than  mother.  .  .  147  boys  to  100  girls. 

Father  1 6  years  and  more  older  than  mother .  163  boys  to  100  girls. 

Goehlert  found  that  the  offspring  of  marriages  in  which  the 
husband  was  younger  than  the  wife  were  71  boys  and  86  girls;  of 
marriages  in  which  husband  and  wife  were  of  the  same  age,  263 
boys  and  282  girls;  and  of  marriages  in  which  the  husband  was 
older  than  the  wife,  2,017  boys  and  1,865  girls. 

Wappaeus,  combining  the  data  supplied  by  these  three  investi- 
gators, Hof acker,  Sadler  and  Goehlert,  obtained  the  following  sexual 
ratios  for  the  entire  8,000  cases  (i.  e.,  the  number  of  boys  born  to 
each  loo  girls  born)  :  When  the  husband  was  younger  than  the 
wife,  88.2 ;  when  husband  and  wife  were  of  the  same  age,  93.5 ; 
when  the  husband  was  older  than  the  wife,  113.0. 

It  will  be  observed  that  the  mean  sexual  ratio  of  these  8,000 
cases  is  109.6;  whilst,  as  we  saw  above,  when  a  sufficiently  large 
number  of  instances  is  taken,  the  sexual  ratio  always  closely  ap- 
proximates to  106.3.  From  this  it  appears  that  the  numbers  dealt 
with  by  Hof  acker,  Sadler  and  Goehlert  in  their  investigations  were 
too  small  for  the  deduction  of  trustworthy  averages. 

The  same  criticism  is  applicable  to  the  observations  of  Ahlfeld, 
Brcslan  and  Noirot,  whose  results  conflict  with  those  just  given. 
According  to  Ahlfeld,  in  the  case  of  1,376  births  where  the  father 
was  at  least  10  years  older  than  the  mother,  the  sexual  ratio  was 
only  98.2.  According  to  Noirot's  data,  in  cases  in  which  the  father 
was  older  than  the  mother,  this  ratio  was  99.7. 


424 


THE  SEXUAL  LIFE  OF  WOMAN. 


Oesterlen  gives  the  following  brief  summary  of  the  researches 
made  for  the  establishment  and  confirmation  of  the  law  of  Hof acker 
and  Sadler: 


AUTHOR. 

Father 
older 
than 
mother. 

Father 
and 
mother 
same 
age. 

Mother 
older 
than 
father. 

Sexual 
ratio. 

Number 
of  in- 
stances. 

Hofacker  

117.  8 

02  .0 

QO  .  6 

107  .  c 

i  ,006 

Sadler  

12  I  .4 

04.8 

86.  t; 

114.7 

2  ,co8 

Goehlert  

108  2 

Q-l  .  •} 

82.6 

ICK  .  7 

4  ,  c84 

Noirot  

GO     7 

1  16  o 

IO3  .  5 

4  ,  ooo 

Legoyt  (Calais)  

IOO    Q 

IO7  .  O 

10  1   6 

IO7  .  Q 

6  ,  006 

Legoyt  (Paris)  

IO4  .  4 

IO2  .  I 

07  .  "? 

IO2  .  O 

S2  ,  71  I 

Breslau  

IQ-i     Q 

IO7  .  I 

1  1  7  .  6 

106  .  6 

8,084 

The  law  of  Hofacker  and  Sadler  cannot  be  regarded  as  possess- 
ing universal  validity,  although  the  figures  on  which  it  is  based  seem 
to  show  pretty  clearly  that  we  are  justified  in  regarding  the  mutual 
interaction  of  the  male  and  female  reproductive  elements  at  the 
moment  of  fertilization  as  effective  in  the  determination  of  sex. 
In  the  investigations  to  which  we  have  hitherto  alluded  it  is  only 
the  relative  ages  of  husband  and  wife  that  have  been  taken  into 
account;  but  other  researches  have  shown  that  the  absolute  age 
alike  of  the  husband  and  of  the  wife  has  an  influence  in  the  de- 
termination of  sex. 

The  influence  of  the  absolute  age  of  the  mother  in  the  determina- 
tion of  sex  has  been  very  clearly  established.  Ahlfcld  was  the  first 
to  draw  attention  to  the  fact  that  among  the  children  of  elderly 
primiparse  there  was  always  to  be  found  an  excess  of  boys,  and 
that  there  was  an  increase  in  this  excess  proportionate  to  the  greater 
age  of  the  mother.  Among  102  children  born  to  primiparse  over 
32  years  of  age  the  sexual  ratio  was  137:100;  and  a  later  investi- 
gation made  by  the  same  author  in  conjunction  with  Schramm 
showed  that  among  1,038  children  born  to  primiparae  over  28  years 
of  age  the  sexual  ratio  was  124:100. 

Hecker  obtained  similar  results.  Among  432  children  born  to 
primiparse  over  thirty  years  of  age  the  sexual  ratio  was  133:100. 
Winckcl,  dealing  with  primiparse  of  the  same  ages,  found  a  sexual 
ratio  of  136.8:100. 

D using,  examining  the  records  of  the  lying-in  hospitals  of  Leip- 


THE  SEXUAL  EPOCH  OF  THE  MENACME. 


425 


zig,  Dresden  and  Jena  and  thus  obtaining  a  very  large  number  of 
instances  whereon  to  base  his  conclusions,  confirmed  the  view  that 
elderly  primiparae  give  birth  to  an  excess  of  boys,  and  further  that 
the  older  they  are  the  larger  the  excess  of  male  births.  He  drew 
up  the  following  table: 


Age  of 
primiparae. 

Leipzig. 
Boys.  Girls. 

Dresden. 
Boys.  Girls. 

Jena. 
Boys.  Girls. 

Total  Nos. 
Boys.  Girls. 

Sexual 
ratio. 

I  e  .  . 

i  ;  

i  ;     2 

i  ;  — 

1  '.       2 

16  

4  :     4 

6  :  10 

2  :  2 

12  :  16 

17.  . 

21  :  1  i 

20  :  i  ? 

o  ;  7 

C2  :   it, 

t?40:404. 

18  

67  :   =;  ^ 

103  :ioo 

n  '.ii 

187:168 

=  1  1  1  .  I 

10.  . 

1  10  1103 

152  1141 

11  '20 

2QZ,  '.271 

20  

148  '147 

187  -i8<: 

72  "4? 

•367  "J.77 

' 

807  '781 

21  

it;?  :i4< 

241  '.2OI 

42  :s? 

440  1404 

=  IOT,  .  1 

22  

I2O  II'?'? 

IQI  I2O7 

48:^ 

1  "5O  '.1Q1 

, 

21  .  . 

106  :io8 

168  1149 

?i  :?i 

12  ?  :^o8 

903:962 

24.  . 

71  :  I  O  ^ 

1  1  1  'i  18 

^7-78 

2  19  :26l 

=93-9 

2  "?.  . 

7O  '    <»7 

77  •    72 

1  $  '27 

187  'IC6 

i 

26  

Af  •      If 

1O  '    47. 

2O  '2O 

12  ?•    08 

27.  . 

•3  i  ;  i  e 

C2  :   ?  ? 

IO  '12 

o?  :io2    • 

531:469 

28  

12  '.     11 

26  '  33 

IQ  "16 

n:  72 

=113.2 

20  .  . 

IQ  ;  10 

26-   18 

4  'I  1 

4O  '    41 

3O.  . 

o  :  is 

7.0:  ii 

o:  6 

48  :  ^4 

* 

•21.. 

*,:     8 

is:  ii 

•i  ;  3. 

2  1  :  22 

72  .  . 

c;      6 

12  :     o 

7  :  ^ 

24:   18 

aa.  . 

2  '        2 

e  •      c 

c  •    2 

12  :     o 

14.  . 

4  :  

8:     <; 

2  I  

14  :     5 

I55:io4 

•7  C.  . 

2  '  

o  t     7 

2  :  i 

1  7  :     4 

=150.0 

16.. 

I  '  

•7  ;     7 

i  '  i 

e  ;      4 

37.  . 

4  ;     i 

4  :     T. 

i  •  — 

Q  :     4 

18.. 

•     j 

i  •  — 

i  '     i 

3Q.  . 

.  

c  ;  

40  

i  :     i 

2  :     i 

i  ;  — 

4  •      2 

41  

:     i 

x  As  an  explanation  of  this  statistically  proved  fact,  that  elderly 
primipane  gave  birth  to  a  large  excess  of  boys,  D using  suggests  that 
these  women  who  conceive  for  the  first  time  comparatively  late  in 
life,  are,  prior  to  the  conception,  in  a  state  corresponding  with  that 
of  a  lower  animal  species  suffering  from  a  deficiency  of  males,  and 
for  this  reason  exhibit  a  tendency  to  procreate  a  larger  number  of 
individuals  of  the  deficient  sex.  In  multiparre  also  it  is  possible  to 
trace  the  influence  of  a  deficiency  of  male  individuals.  When  there 
is  such  a  deficiency  the  interval  between  successive  births  is  unduly 
protracted.  D  using  found  (once  more  from  the  records  of  the 
lying-in  hospitals  of  Dresden,  Leipzig  and  Jena)  that  the  longer 


426 


THE  SEXUAL  LIFE  OF  WOMAN. 


the  interval  between  one  parturition  and  the  next  the  longer,  that 
is  to  say,  the  mother  has  had  to  wait  for  her  next  conception,  the 
greater  is  the  excess  of  male  births.  Diising  therefore  lays  down 
the  law :  "  Delayed  impregnation  gives  rise  to  an  excess  of  male 
births." 


Interval  in 
years. 

Leipzig. 
Boys.  Girls. 

Dresden. 
Boys.  Girls. 

Jena. 
Boys.  Girls. 

Total  Nos. 
Boys.  Girls. 

Sexual 
ratio. 

i  

162  '158 

IQJ.  'I  78 

s8'  d< 

At  A  '781 

108  6 

2  

766  "*O7 

7  7/1  '761 

168  'i/ic 

908-813 

198  '196 

I  16  '  94 

4    . 

127  '109 

CO  '     4  C 

c  .  . 

en  ;  CA 

e  e  •    CA 

7.8-   78 

T  C2  'Id.fl 

"5-7 

6  

61  :  62 

f2  '    A.Q 

A.Q  '     2A. 

162  'I  7  C 

8,  9  and  10  

18:  16 

A.1'    21 

1  6  '  24 

7  (  '    67 

121     O 

ii  and  more.  .  .  . 

25:  15 

12  :     9 

4:     6 

4i:    30 

Totals:   4,903  births,  2,591  m. ;  2,312  f. ;  sexual  ratio  =  112.06. 

Bidder  considers  that  his  own  observations  entitle  him  to  modify 
Ahl  f  eld's  dictum  regarding  the  influence  of  age  in  primiparae  in 
giving  rise  to  an  excess  of  male  births.  He  tabulates  his  results 
as  follows: 


AGE  OF  MOTHER. 

Number 
of  cases. 

Sexual 
ratio. 

17  to  20  

80 

2O  tO   22  

AO  C 

22    to   24  

24  to  26  

I      178 

104  6 

26  to  30  

2     OJ.O 

10  c    c 

TO   tO   72  .  . 

878 

112? 

72   tO    76.  . 

I     I2O 

7,6  tO    70.  . 

676 

40  and  upward  

2  I  C 

171     < 

and  formulates  the  following  thesis:  Very  young  primiparae  give 
birth  to  an  excess  of  boys ;  primiparae  in  the  first  bloom  of  woman- 
hood give  birth  to  an  excess  of  girls ;  later,  however,  as  the  age 
of  the  primiparae  increases  the  excess  of  male  births  soon  reappears 
and  rapidly  increases. 

Hofacker's  data  and  the  researches  of  Hampe  agree  with  those 
of  Bidder  in  showing  that  to  very  young  primiparae,  as  well  as  to 


THE  SEXUAL  EPOCH  OF  THE  MENACME. 


427 


elderly  primiparae,  an  excess  of  boys  is  born.  Among  the  offspring 
of  363  mothers,  at  ages  varying  from  16  to  26  years,  Hofacker 
found  the  sexual  ratio  to  be  121 ;  among  the  offspring  of  1,056 
mothers,  at  ages  26  to  36,  the  ratio  was  101 ;  and  among  the  off- 
spring of  567  mothers  at  ages  36  to  46,  the  ratio  was  in.  Hampe 
tabulated  5,992  instances  as  follows: 


AGE  OF  MOTHER. 

Number 
of  in- 
stances. 

Sexual 
ratio. 

Below  20  years  

c6 

IO7    7 

20  to  25  years  

871 

90     6 

25  to  30  years  

i  .  6"*"? 

lid.    O 

•?o  to  T,  z.  years.  . 

i   6^  i 

108   3 

3  5  to  40  years  

i    i8< 

117     I 

Over  40  years  

616 

12.1    O 

We  learn,  therefore,  that  if  the  age  of  the  progenitors  is  to  be 
regarded  as  one  of  the  causes  by  which  sex  is  determined,  we  must 
take  into  consideration  not  only  the  relative  ages  of  husband  and 
wife  but,  in  addition,  the  absolute  age  of  the  wife. 

Goehlert  undertook  a  statistical  investigation  in  which  the  abso- 
lute age  of  the  husband  was  taken  into  consideration  as  well  as 
that  of  the  wife.  From  this  it  appeared  that  the  maximum  sexual 
ratio  was  exhibited  when  the  father  was  between  the  ages  of  30 
and  35  years.  When  the  age  of  the  mother  is  treated  as  the  de- 
termining- influence,  we  find  the  maximum  sexual  ratio  in  the  off- 
spring of  mothers  between  the  ages  of  25  and  30  years.  Goehlert 
believes,  however,  that  the  paternal  influence  is  more  powerful  than 
the  maternal  in  the  determination  of  sex.  The  respective  influences 
are  compared  in  the  following  table: 

AGE  OF  MOTHER. 


AGE  OF  FATHER. 

20  to  30 
years. 

30  to  40 
years. 

Over  40 
years. 

Totals. 

2  S  to  •?  s  years  . 

ICK   76 

107  .  87 

109  .  14 

106  .  6 

•?  ?  to  4s  years  .  . 

102     8 

IO5     I 

10?  .  •? 

104  .  7 

Over  45  years  

104   •? 

103  o 

IOO  .  1 

In  general  

TO  s     2s" 

IOS    07 

104  .  9 

iOs  .  «; 

428  THE  SEXUAL  LIFE  OF  WOMAN. 

Gcisslcr,  studying  the  data  obtainable  regarding  the  sexual  ratio 
during  a  lo-year  period  in  the  Kingdom  of  Saxony,  ascertained 
that  in  families  possessing  two  children  or  more  there  was  a  very 
definite  distribution  of  the  possible  sex-combinations.  Where  there 
was  an  even  number  of  children  those  families  were  in  the  ma- 
jority in  which  the  number  of  boys  and  girls  was  identical.  If  the 
number  of  children  in  the  family  is  an  unequal  one,  those  combi- 
nations are  most  frequent  in  whicn  the  number  of  boys  exceeds  the 
number  of  girls  by  one;  next  in  frequency  are  those  combinations 
reversed  to  this,  i.  e.,  in  which  the  number  of  girls  exceeds  the 
number  of  boys  by  one.  All  other  combinations  are  comparatively 
infrequent  in  proportion  as  the  discrepancy  in  number  between 
boys  and  girls  is  larger.  Rarest  of  all  are  families  in  which  the 
children  are  all  of  the  same  sex ;  and  among  these,  again,  the  most 
unusual  are  those  consisting  of  boys  only. 

This  distribution  of  the  sex-combination  is  believed  by  Geissler 
to  depend  upon  the  fact  that  in  the  first  birth  and  all  the  subse- 
quent births  there  is  generally  speaking  a  slight  advantage  in 
favour  of  the  male  sex.  It  has  not  been  proved  that  the  sex  of 
the  first-born  exercises  a  determining  influence  on  the  sex  of  the 
subsequent  children.  It  does,  however,  seem  clear  that  in  the  case 
of  parents  who  have  given  birth  in  succession  to  several  children 
of  one  sex  only,  there  exists  some  definite  obstacle  to  the  procreation 
of  children  of  the  opposite  sex.  Putting  these  exceptions  out  of 
consideration,  there  seems  to  exist  a  tendency  in  the  later  births 
of  a  series  toward  the  procreation,  more  especially  of  that  sex 
which  has  been  absent  or  deficient  in  the  earlier  births  of  the  series. 
The  strength  of  this  equalizing  tendency  increases  as  soon  as  it  has 
for  the  first  time  manifest  itself.  It  is  always  greater  when 
the  sex  deficient  in  the  earlier  births  of  the  series  has  been  the 
male. 

I  have  myself  undertaken  a  statistical  investigation  of  the  births 
occurring  in  the  reigning  families  of  Europe  and  in  the  families 
of  the  leading  members  of  the  aristocracy.  The  necessary  particu- 
lars are  to  be  obtained  from  the  genealogical  court  calendars ;  and 
it  is  my  belief  that  the  data  obtained  regarding  these  uppermost 
strata  of  society  are  comparatively  free  from  many  sources  of  error 
by  which  the  ordinary  statistics  of  the  subject  are  apt  to  be  invali- 
dated. For  556  marriages  there  were  1,9/2  births,  comprising  1,023 
boys  and  949  girls,  and  thus  exhibiting  a  sexual  ratio  of  107.7. 

In  relation  to  the  relative  ages  of  the  parents,  the  following  table 
was  drawn  up: 


THE  SEXUAL  EPOCH  OF  THE  MENACME. 


429 


Boys. 

Girls. 

Sexual 
ratio* 

Husband  older  than  wife  by  one  to  five 
years  

2O4. 

281 

101   8 

Husband  older  than  wife  by  more  than 
five  and  less  than  ten  years  

327 

106 

106  8 

Husband  older  than  wife  by  more  than 
ten  and  less  than  fifteen  years    

IOO 

167 

113     7 

Husband  older  than  wife  by  more  than 
fifteen  years  

n8 

TI* 

122     I 

Husband  same  age  as  wife  

•24. 

42 

80   9 

Husband  younger  than  wife  

4O 

^8 

IOC     2 

From  these  figures  we  may  deduce  the  following  conclusions, 
which  are  not  wholly  concordant  with  the  law  of  H  of  acker  and 
Sadler:  When  the  husband  is  older  than  the  wife  the  excess  of 
male  births  among  the  offspring  is  greater  than  it  is  in  the  case  of 
an  average  drawn  from  the  offspring  of  all  marriages  (in  my  cases 
the  difference  was  111.8  as  compared  with  107.7).  But  a  closer 
analysis  shows  the  difference  to"  be  less  simple  than  at  first  sight 
appears.  If  the  husband  is  older  than  the  wife  by  one  to  five  years, 
the  excess  of  male  births  among  their  offspring  (103.8)  is  less 
than  in  the  average  of  all  marriages  (107.7)  5  the  same  is  true  of 
the  offspring  of  marriages  in  which  the  husband  is  more  than  five 
and  less  than  ten  years  older  than  the  wife,  though  the  difference 
here  is  very  trifling  (106.8  as  compared  with  107.7).  It  ^s  n°t  till 
we  come  to  the  offspring  of  marriages  in  which  the  husband  is 
from  ten  to  fifteen  years  older  than  the  wife  that  the  increase  in 
the  excess  of  male  births  becomes  notable  (113.7  as  compared  with 
107.7)  >  and  when  the  husband  is  more  than  fifteen  years  older  than 
the  wife  the  excess  of  males  is  higher  still  (122.1). 

If  we  arrange  these  data  so  as  to  show,  in  cases  in  which  the 
husband  is  older  than  the  wife,  the  additional  influence  of  the 
absolute  age  of  the  wife,  we  obtain  results  which  partially  conflict 
with  those  of  Bidder,  as  follows: 


HUSBAND  OLDER  THAN  WIFE. 

Boys. 

Girls. 

Sexual 
ratio. 

Wife's  age,  15  to  20  years  

280 

287 

07  .  6 

Wife's  age,  20  to  26  years  

entr 

SlJt 

116  .0 

Wife's  age,  26  to  33  years  

60 

no  .  i 

430  THE  SEXUAL  LIFE  OF  WOMAN. 

Thus  we  see  that  when  the  wife  is  very  young,  i.  e.,  less  than 
twenty  years  of  age,  even  though  the  husband  is  older  than  the  wife, 
there  is  among  their  offspring  no  excess  of  male  births,  but  the 
contrary  —  a  sexual  ratio  of  97.6  only.  Most  marked  is  the  excess 
of  boys  in  cases  in  which  the  husband  is  older  than  the  wife,  and 
the  age  of  the  wife  is  from  twenty  to  twenty-five  years.  When  the 
husband  is  older  than  the  wife,  and  the  wife's  age  lies  between 
twenty-five  and  thirty-two  years,  the  excess  of  male  births  is  not 
so  great,  though  still  considerable. 

Hence  it  appears  that  the  law  of  Hofacker  and  Sadler,  which 
cannot  be  regarded  as  fully  valid  in  the  terms  in  which  it  was 
originally  expressed,  must  be  modified  as  follows:  If  the  husband 
is  at  least  10  years  older  than  the  wife,  and  the  latter  is  at  an  age 
when  her  reproductive  capacity  is  at  its  maximum  (twenty  to  twenty- 
five  years),  the  offspring  exhibit  a  notable  excess  of  male  births. 
There  is  still  a  considerable  excess  of  male  births  in  the  offspring 
of  marriages  in  which  the  husband  is  at  least  ten  years  older  than 
the  wife,  and  the  wife  is  more  than  twenty-five  years  of  age.  On 
the  other  hand  fewer  boys  are  born  than  girls  as  the  offspring  of 
marriages  in  which,  although  the  husband  is  older  than  the  wife, 
the  wife  has  not  yet  attained  the  age  of  maximum  reproductive 
capacity  —  i.  e.,  is  less  than  twenty  years  of  age.  The  excess  of 
female  births  is  most  marked  when  the  husband  and  wife  are  of 
the  same  age.  When  the  wife  is  older  than  the  husband  there  is 
a  moderate  excess  of  male  births. 

I  admit,  however,  that  the  figures  upon  which  I  have  based  these 
conclusions  are,  like  those  of  Hofacker,  too  few  in  number  for  the 
foundation  of  trustworthy  inferences.  The  instances  in  my  com- 
putation number  1,972;  those  in  that  of  Hofacker,  1,996;  but,  as  I 
have  already  remarked,  there  are  reasons  for  believing  that  the 
data  I  have  employed  admit  of  the  introduction  of  fewer  sources 
of  error. 

The  influence  of  the  absolute  age  of  the  mother  in  the  determina- 
tion of  sex  having  been  statistically  proved,  many  have  inferred 
that  this  determination  is  not  effected  during  the  instant  of  fertiliza- 
tion, but  occurs  at  a  later  stage  of  intra-uterine  life,  and  is  influ- 
enced by  the  manner  in  which  the  embryo  is  nourished  by  the 
maternal  organism.  It  is  suggested  that  elderly  and  immature 
mothers  are  unable  to  furnish  the  embryo  with  nutriment  so  well 
as  those  mothers  who  are  at  the  age  of  maximum  reproductive 
capacity,  and  that  upon  this  fact  depends  the  excess  of  male  births 


THE  SEXUAL  EPOCH  OF  THE  MENACME. 


in  the  latter  case.  (We  shall  return  to  this  matter  —  the  influence 
of  deficient  nutrition  in  relation  to  the  excess  of  male  births).  But 
the  proof  of  the  fact  that  the  absolute  age  of  the  father  has  also 
an  influence  in  the  determination  of  the  sex  of  the  offspring  offers 
a  ground  for  opposing  this  assumption  that  the  sex  of  the  em- 
bryo is  determined  during  intra-uterine  life  subsequent  to  fertiliza- 
tion, and  suggests  that  the  father  also  exercises  a  determining 
influence  in  the  origination  of  sex  during  the  act  of  fertilization. 

The  absolute  age  of  the  husband  seems  also  to  have  some  influ- 
ence upon  the  sexual  ratio.  The  absolute  age,  like  the  relative  age, 
of  the  father  appears  favourable  to  the  procreation  of  a  greater 
excess  of  boys.  Thus,  H  of  acker  found  in  1,193  cases,  in  which 
the  age  of  the  father  was  from  twenty-four  to  thirty-six  years,  that 
the  sexual  ratio  was  100;  in  683  cases  in  which  the  age  of  the  father 
was  from  thirty-six  to  forty-eight  years,  the  sexual  ratio  was  114; 
and  in  105  cases,  in  which  the  age  of  the  father  was  from  forty- 
eight  to  sixty  years,  the  sexual  ratio  was  169. 

In  investigations  based  upon  larger  collections  of  cases  Schumann 
and  D Using  have  endeavoured  to  determine  the  variation  in  the 
sexual  ratio  according  to  the  absolute  age  of  the  father. 

D  using  examined  the  statistics  of  births  in  Norway,  Alsace-Lor- 
raine and  Berlin,  and  from  the  data  thus  obtained  he  compiled  the 
following  table: 


AGE  OP  MOTHER. 

30  TO  35  YEARS. 

25  TO  30  YEARS., 

20  TO  25  YEARS. 

AGE  OF  FATHER. 

Boys. 

Girls. 

Sexual 
ratio. 

Boys. 

Girls. 

Sexual 
ratio. 

Boys. 

Girls. 

Sexual 
ratio. 

15  to  30  years.    .  .    . 
30  to  3  s  years.    .  .    . 
35  to  40  years.    .  .    . 
40  to  45  years.    .  .    . 
Over  45  years.    .  .    . 

8,525 
23.283 
17,885 
7,972 

4,220 

7.887 
21.823 
17,070 
7,681 
3.997 

08.  i 
06.9 
04.7 
03.8 
05.6 

27,389 
23.394 
10,272 
3,165 
1.734 

25,843 
23,486 
9,838 
3.058 
i.  52S 

06.0 

03-9 
04.2 
03.5 
13-8 

21  ,560 

7.9S4 
2,426 

}  1,154 

20,330 
7.469 
2,416 

1,100 

106.0 
1  06  .  5 
100.4 

105.0 

In  this  table  we  find  the  births  arranged  in  relation  to  varying 
ages  of  the  fathers  and  in  relation  to  mothers  whose  ages  are  tabu- 
lated in  three  classes,  the  ages  of  the  latter  being  those  at  which 
they  are  most  prolific.  The  table  shows  clearly  that  the  excess  of 
boys  is  larger  at  the  beginning  and  at  the  end  of  each  column. 
Thus,  the  age  of  the  mother  remaining  constant,  young  fathers  and 
elderly  fathers  procreate  a  larger  proportion  of  boys  than  do  fathers 
of  intermediate  age. 


432  THE  SEXUAL  LIFE  OF  WOMAN. 

But  I  find  in  this  table,  which  is  based  upon  a  very  large  number 
of  instances  indeed,  a  confirmation  of  the  thesis  which  I  stated 
above,  for  the  highest  sexual  ratio  of  113.8  is  in  this  table  found 
in  the  case  of  fathers  over  forty-five  years  of  age  who  are  married 
to  mothers  of  ages  twenty-five  to  thirty  years ;  this  is,  as  I  said, 
the  case  in  which  "  the  husband  is  at  least  ten  years  older  than  the 
wife,  and  the  latter  is  at  the  age  at  which  her  reproductive  capacity 
is  at  its  maximum." 

From  such  figures  as  these,  which  seem  to  show  the  influence  of 
the  absolute  age  of  the  father  upon  the  determination  of  sex,  it 
has  by  many  been  inferred  that  the  man  exercises  a  preponderating 
influence  upon  the  determination  of  the  sex  of  the  embryo,  im- 
pressing his  own  sex  upon  it,  and  that  the  greater  the  sexual  potency 
of  the  begetter  the  more  powerful  also  is  the  influence  exercised 
by  the  latter;  that  the  point  of  first  importance  in  this  connection 
is  the  sexual  capacity  of  the  man;  and  that  the  excess  of  male 
births  increases  pari  passu  with  the  increase  in  the  potency  of  the 
procreating  male. 

Two  additional  considerations  have  been  adduced  to  demonstrate 
the  influence  of  the  father  in  determining  the  sex  of  the  offspring. 
The  first  of  these  is  a  comparison  of  the  ratio  between  male  and 
female  births  in  towns  and  in  rural  districts,  respectively;  and  the 
second  is  a  comparison  between  the  ratio  of  males  to  females  in 
the  offspring  of  married  and  of  unmarried  .parents,  respectively. 

In  towns  the  excess  of  male  births  is  smaller  than  it  is  in  the 
country.  The  average  sexual  ratio  in  Prussia  during  the  five-year 
period,  1875  to  1880,  is  given  by  Diising  as  follows: 

In  Berlin 105 . 70 

In  other  large  towns 105 . 72 

In  medium  sized  towns 105 . 44 

In  small  towns 106 . 1 7 

In  rural  districts 106 . 62 

The  indisputable  fact  that  in  towns  more  girls  are  born  than  in 
rural  districts  is  referred  to  the  fact  that  in  the  country  the  hus- 
band usually  enters  on  marriage  with  his  virile  powers  completely 
unimpaired,  whereas  in  towns  many  men  only  marry  after  they 
have  for  many  years  expended  their  best  forces  in  irregular  sexual 
intercourse,  and  thus  reserve  for  their  wives  only  the  dregs.  But, 
as  we  shall  show  presently,  the  difference  between  town  and  country 
in  this  respect  is  susceptible  of  a  different  interpretation. 

It  has  also  been  asserted  (Horn}  that  extra-conjugal  sexual  in- 
tercourse is  favourable  to  the  procreation  of  boys,  the  suggestion 


THE  SEXUAL  EPOCH  OF  THE  MENACME.  433 

being  that  the  greater  sexual  vigour  in  the  former  case  determines 
a  preponderance  of  males  in  the  offspring;  but  this  assumption  is 
invalidated  by  the  statistical  evidence  which  now  accumulates,  that 
among  illegitimate  offspring  there  is  a  smaller  excess  of  boys  than 
among  legitimate  offspring.  Babbage,  for  instance,  came  to  this 
conclusion  as  a  result  of  the  comparison  of  1,000,000  illegitimate 
births  with  14,000,000  legitimate  births.  On  the  other  hand,  the 
following  utterance  of  Ploss  appears  extremely  artificial :  "  In  a 
country  in  which  illegitimate  births  are  very  numerous,  in  which 
the  illegitimate  children  are  for  the  most  part  begotten  by  enervated 
debauchees,  the  excess  of  male  births  is  smaller;  but  in  a  country 
in  which  the  illegitimate  births  are  less  numerous,  and  in  which  the 
illegitimate  infants  are  for  the  most  part  the  fruit  of  love  and  are 
begotten  by  youthful  lovers,  the  excess  of  male  offspring  is  larger." 

Next  to  the  age  of  the  progenitors,  their  nutritive  condition  is 
shown  by  statistical  investigations  to  exercise  an  important  influ- 
ence in  the  determination  of  sex.  The  following  proposition  has, 
in  fact,  been  established :  Where  the  supply  of  nutriment  is  de- 
ficient, the  offspring  contains  an  excessive  proportion  of  boys. 

Ploss,  in  an  article  on  "  The  Causes  of  Variations  in  the  Sexual 
Ratio,"  published  in  twelfth  volume  of  the  "  Berliner  geburtsh. 
Monatsheft,"  has  collected  a  number  of  statistical  data  to  demon- 
strate that  the  determination  of  sex  is  principally  dependent  upon 
the  nutritive  condition  of  the  mother.  In  his  opinion  the  determi- 
nation of  the  sex  of  the  embryo  depends  neither  upon  the  quality 
of  the  ovum  nor  upon  that  of  the  spermatozoon,  nor  again  upon 
the  reciprocal  influences  exerted  by  ovum  and  spermatozoon  on 
one  another.  During-  the  earliest  time  after  fertilization  the  embryo 
is  sexually  neutral  and  only  later,  as  a  result  of  some  new  influ- 
ence acting  upon  it,  does  it  receive  an  impulse  toward  the  formation 
either  of  the  male  or  of  the  female  sex.  Among  all  the  external 
conditions  which  are  capable  during  this  period  of  exercising  a 
determinative  influence  the  most  important  are  the  nutritive  con- 
ditions, for  nutrition  is  the  most  important  factor  in  determining 
the  form  of  the  young  animal,  and  most  of  the  other  outward 
conditions,  such  as  light,  heat,  and  chemical  changes,  affect  the 
embryo  in  a  mediate  manner  only,  through  the  changes  they  are 
respectively  capable  of  inducing  in  its  nutrition  and  metabolism. 
But  Ploss  is  not  content  with  asserting  that  the  nutritive  condition 
of  the  mother  is  of  great  importance  in  determining  the  sex  of  the 
embryo;  he  goes  further  than  this,  and  declares  that  it  is  scanty 
28 


434  THE  SEXUAL  LIFE  OF  WOMAN. 

nutrition  of  the  mother  which  especially  gives  rise  to  the  birth  of 
males,  whereas  abundant  nutrition  of  the  mother  tends  to  give  rise 
to  the  birth  of  females.  He  refers  to  observations  made  in  respect 
of  other  animals  than  man.  St.  Hilaire  observed  that  among  the 
underfed  animals  in  menageries  there  was  an  excess  of  male  births. 
Hof acker  and  Girou  de  Bazareinyues  have  noted  similar  phenomena 
in  the  case  of  domestic  animals;  they  found  that  when  these  were 
richly  fed  they  gave  birth  to  an  excess  of  females,  but  that  when 
they  were  poorly  nourished  they  gave  birth,  on  the  contrary,  to  an 
excess  of  males.  Among  sheep,  with  whom  the  number  of  male 
and  of  female  births  is  approximately  identical,  Martegoute  found 
that  those  animals  which  had  given  birth  to  female  lambs  had  on  the 
average  a  greater  weight  than  those  ewes  which  had  given  birth  to 
male  lambs.  During  the  period  of  lactation,  also,  the  former  lost 
weight  more  than  the  latter. 

When  Ploss  had  further  ascertained  that  among  those  engaged 
in  the  fur-trade  it  is  the  established  belief  that  from  fruitful  regions 
the  skins  chiefly  of  female  animals  will  be  obtained,  but  from  barren 
regions,  on  the  other  hand,  among  the  skins  obtained  those  of  male 
animals  will  preponderate,  it  appeared  to  him  that  he  was  justified 
in  drawing  the  conclusion  that  among  the  mammalia  a  well-nour- 
ished mother,  one  capable  of  providing  abundant  nutriment  for 
her  offspring,  is,  on  the  whole,  more  likely  to  give  birth  to  a  female 
than  to  a  male,  and  conversely.  He  then  endeavoured,  by  refer- 
ence to  the  statistics  of  population,  to  show  that  in  the  case  of 
human  beings  also,  when  the  mother  is  exceptionally  well  nourished, 
there  is  especial  likelihood  of  a  girl  being  born ;  whereas  when  the 
mother  is  ill  nourished  she  is  more  likely  to  give  birth  to  a  boy  — 
odd  as  it  may  seem,  at  first  sight,  that  a  rich  diet  should  determine 
the  production  of  the  so-called  less  powerful  sex,  the  female;  and 
conversely.  (Ploss,  be  it  noted  however,  denies  that  male  new- 
born infants  are  more  powerful  than  female.)  The  fact  that  in 
the  country,  comparatively  speaking,  many  more  boys  are  born  than 
in  towns  (vide  supra)  is  explained  by  Ploss  as  dependent  on  the 
fact  that  townswomen  are  on  the  whole  better  nourished  than  the 
countrywomen,  owing  to  the  greater  consumption  of  meat  by  the 
former. 

The  circumstance  again  (likewise  alluded  to  above),  that  in  the 
case  of  illegitimate  births  almost  always  the  excess  of  male  births 
is  less  marked  than  in  the  case  of  the  offspring  of  legal  unions,  is 
regarded  by  Ploss  as  offering  further  proof  of  the  influence  of 


THE  SEXUAL  EPOCH  OF  THE  MENACME.  435 

nutritive  conditions  upon  the  determination  of  sex.  Illegitimate 
mothers  are  on  the  average  women  at  the  very  best  age  for  child- 
bearing,  women  who  have  worked  vigorously,  are  themselves  well 
nourished,  and  are  therefore  better  able  to  nourish  their  unborn 
offspring  than  (on  the  average)  married  women.  Further,  it  is 
a  remarkable  fact  that  in  Saxony,  regions  of  which  the  elevation 
above  the  sea-level  is  less  than  1,000  feet,  produce  comparatively 
more  girls  than  regions  at  an  altitude  of  1,000  to  2,000  feet  above 
the  sea.  This  Ploss  refers  to  the  worse  nutrition  of  the  women 
living  at  the  higher  altitude,  for  the  fact  is  well  known  that  the 
higher  we  go  above  the  sea  the  less  fertile  is  "the  soil  and  the  more 
limited  is  its  produce. 

Starting  from  the  view  that  the  lower  classes  of  the  population 
are  in  good  years  better  nourished  than  they  are  in  bad  years, 
Ploss  compared  statistically  the  rise  and  fall  of  the  prices  of 
foodstuffs,  in  Saxony,  with  the  variations  of  the  sexual  ratio  in  the 
same  kingdom ;  and  he  found,  in  correspondence  with  his  theory, 
that  in  bad  times  there  was  a  greater  excess  of  male  births  than 
there  was  during  periods  in  which  food  was  cheaper.  Moreover, 
the  consumption  of  meat  appeared  to  have  more  influence  upon  the 
variations  in  the  sexual  ratio  than  was  exercised  by  the  consump- 
tion of  vegetable  food-stuffs.  Ploss  endeavoured  to  show  graphi- 
cally that  with  an  increase  in  the  price  of  provisions  there  corre- 
sponded an  increase  in  the  excess  of  male  births,  and  vice  versa. 

That  after  times  of  great  wars,  pestilence,  and  emigration,  in 
which  the  male  portion  of  the  population  has  been  decimated, 
there  occurs  a  notable  increase  in  the  excess  of  male  births,  is  ex- 
plained by  Ploss  by  the  assumption  that  in  consequence  of  the 
deficiency  of  male  labour,  the  general  supply  of  provisions  is  de- 
ficient, just  as  it  is  after  years  of  bad  harvests;  hence,  in  conse- 
quence of  the  scanty  nutrition  of  the  mothers,  the  number  of  female 
births  is  depressed  and  the  number  of  male  births  increases.  Those 
countries  which  in  general  possess  a  more  thriving  population,  such 
as  Saxony,  England,  Belgium,  Prussia,  etc.,  exhibit  a  smaller  excess 
of  male  births  when  compared  with  those  countries  in  which  a  more 
widespread  poverty  exists,  such  as  Russia,  Lombardy,  Bohemia, 
and  even  France.  With  increasing  prosperity,  fruitfulness  in- 
creases, and  there  is  an  increase  also  in  the  proportion  of  female 
births. 

These  views  of  Floss's  are,  however,  rightly  contested  by  Breslau 
and  Wappacus. 


436  THE  SEXUAL  LIFE  OF  WOMAN. 

Breslau  ("The  Causes  of  the  Determination  of  Sex")  offers  in 
the  first  place  theoretical  objections  to  the  view  that  nutritive  con- 
ditions in  the  mother  are  determinative  in  the  production  of  the  sex 
of  the  offspring;  and  he  then  proceeds  to  quote  statistical  data 
which  are  opposed  to  any  such  theory.  He  rightly  insists,  in  the 
first  place,  that,  inasmuch  as  it  is  unquestionable  that  in  the  act  of 
fertilization  the  spermatozoon  induces  in  the  ovum  certain  changes, 
the  effect  of  which  is  manifested  in  days  far  later  than  those  of 
intra-uterine  life,  by  the  production  of  the  most  manifold  and  var- 
ious somatic  and  psychical  resemblances  to  the  father,  it  is  obvious 
that  this  single  occurrence  of  the  fusion  of  the  spermatozoon,  the 
bearer  of  the  paternal  influences,  with  the  ovum  is  competent  to 
induce  in  the  ovum  a  molecular  arrangement  upon  which  the  de- 
termination of  sex  may  be  supposed  to  depend  —  it  is  not  neces- 
sary to  suppose  that  for  this  determination,  repeated  actions,  or  a 
prolonged  period  of  time,  is  requisite. 

In  this  connection  a  reference  to  birds  is  instructive,  for  in  this 
division  of  the  animal  kingdom  we  seem  absolutely  compelled  to 
assume  that  the  sex  of  the  offspring  is  irrevocably  determined  in  the 
moment  of  fertilization.  "  In  birds,  who  lay  an  egg  every  day, 
eggs  which  are  kept  all  at  the  same  temperature  during  the  period 
of  incubation,  and  some  of  which  develop  into  cock  and  others  into 
hen  birds  —  how  is  it  possible  to  imagine  that  the  nutritive  condi- 
tion of  the  parent  is  determinative  of  the  sex  of  the  offspring, 
since  this  nutritive  condition  cannot  reasonably  be  supposed  to 
change  to  any  notable  extent  from  one  day  to  the  next  and  then 
back  again  ?  " 

The  paternal  influence  in  the  determination  of  sex  is  regarded 
by  Breslau  as  likely  to  be  at  least  as  important  as  that  exercised 
by  the  mother.  Unquestionably  the  semen  is  subject  to  certain 
variations  in  quality  and  in  quantity,  and  it  is  possible  that  these 
variations  may  make  themselves  felt  in  the  subsequent  development 
of  the  embryo.  Of  the  semen,  as  of  all  secretions,  we  can  assume 
with  some  probability  that  in  certain  conditions  (conditions  which 
are,  indeed,  but  little  understood),  it  may  exhibit  a  greater  or  less 
intensity  in  its  stimulating  qualities,  and  that  in  this  way  it  may  be 
subject  to  changes,  according  to  which  it  will  tend  to  influence  the 
development  of  the  embryo,  now  in  the  female,  and  now  in  the 
male  direction.  Again,  in  view  of  the  continued  interchange  of 
nutritive  materials  between  the  embryo  and  the  maternal  organism, 


THE  SEXUAL  EPOCH  OF  THE  MENACME.  437 

it  is  probable  enough  that  the  constitution  of  the  maternal  organism 
and  likewise  that  of  the  ovum,  at  the  moment  of  fertilization,  are 
not  matters  of  indifference  to  the  determination  of  sex.  But  to 
attribute  to  the  nutritive  condition  of  the  maternal  organism  the 
sole  or  even  the  principal  influence  in  the  determination  of  the  sex 
is  an  unjustifiable  assumption. 

The  proofs  alleged  by  Ploss  from  the  animal  world  in  support  of 
his  thesis,  viz.,  that  in  the  case  of  poorly  nourished  animals  there  is 
a  marked  excess  of  male  offspring,  are  justly  controverted  by 
Breslau  with  the  remark  that  the  observations  on  animals  are  but 
few  in  number,  and  further  that  we  know  nothing  whatever  regard- 
ing the  normal  sexual  ratios  among  the  offspring  of  such  animals 
as  lions,  tigers,  hyaenas,  bears,  etc.,  in  the  free  state. 

If,  again,  domestic  animals  when  well  nourished  give  birth  to  an 
excess  of  female  offspring,  and  when  ill  nourished  and  overworked 
to  an  excess  of  male  offspring,  in  the  former  case  we  can  only  regard 
the  excess  of  female  births  as  a  pathological  phenomenon,  inasmuch 
as  a  superabundant  supply  of  nutriment  is  not  that  which  furnishes 
the  highest  powers  or  is  most  suited  to  the  preservation  of  life. 
Again,  the  accounts  given  by  fur-dealers  are  quite  untrustworthy, 
since  these  men  commonly  obtain  their  goods  at  third,  and  fourth 
hand;  moreover,  most  of  the  animals  whose  pelts  form  articles  of 
commerce,  are  beasts  of  prey,  such  as  the  otter,  the  lynx,  the  bear, 
the  wolf,  the  fox,  etc.  —  and  these  animals  have  no  "  pasturage." 
Among  vegetable-feeding  animals  the  females  are  no  doubt  found 
on  the  pasturage  more  often  than  the  males,  for  the  reason  that  the 
females  have  to  nourish  both  themselves  and  their  young,  whereas 
the  males,  which  have  themselves  only  to  provide  for,  are  contented 
with  less  food  and  inhabit  chiefly  more  retired  and  less  fertile 
regions;  they  are  also  shyer  and  are  less  easily  shot  and  trapped. 
Regarding  statistical  data  relating  to  the  influence  of  nutrition  on 
the  production  of  boys,  Breslau  shows,  from  the  figures  of  the 
Canton  of  Zurich,  that  with  few  exceptions,  the  years  in  which  the 
price  of  corn  was  lowest  were  the  years  in  which  the  production  of 
boys  was  greatest,  and  vice  versa,  —  the  exact  opposite  of  the  re- 
sults obtained  by  Ploss  from  his  examination  of  the  figures  relat- 
ing to  births  and  the  price  of  provisions  in  Saxony. 

Wappacus  contests  the  conclusions  of  Ploss  even  more  vigorously, 
and  adduces  the  statistics  of  Sweden  in  the  2O-year  period  1770 
to  1790,  in  which  period  this  kingdom  repeatedly  suffered  from 


438  THE  SEXUAL  LIFE  OF  WOMAN. 

famine  in  consequence  of  failure  of  the  crops,  so  that  the  births  and 
deaths  were  largely  affected.  It  appeared,  however,  that  the  more 
abundant  or  more  scanty  nutrition  of  the  inhabitants  of  Sweden 
during  this  period  had  no  marked  influence  upon  the  sexual  ratio. 

If  scanty  nutrition  of  the  mother  had,  in  fact,  any  influence  upon 
the  determination  of  the  sex  of  the  embryo  in  the  direction  al- 
leged by  Ploss,  viz.,  so  as  to  bring  about  the  birth  of  a  greater  ex-, 
cess  of  boys,  this  influence  should  be  manifested  with  exceptional 
clearness  in  the  case  of  twins,  for  it  is  obvious  that  the  nutriment 
that  is  insufficient  for  one  embryo  would  be  still  scantier  for  two. 
Hence  various  statistical  investigations  have  been  undertaken  to  de- 
termine the  sexual  ratio  in  the  case  of  twin  births.  Ploss  found 
that  in  Saxony,  in  the  case  of  23,420  twin  births,  the  sexual  ratio 
was  106.7  boys  to  100  girls ;  Moscr  gives  the  sexual  ratio  in  the 
case  of  twin  births  as  106;  Meckel  von  Hemsbach  gives  it  as  105.4; 
Hecker,  116  and  122;  Sickel,  112.3.  D Using  combined  the  figures 
relating  to  twin  births  in  various  lying-in  hospitals,  published  by 
Hecker,  Sickel;  Baillarger,  Siebold,  Elsdsscr,  and  Levy,  respectively, 
and  thus  obtained  a  sexual  ratio  of  121.5  boys  to  100  girls.  This 
excess  of  boys  is  notably  greater  than  among  births  in  general. 

But  other  statistical  data  are  available  which  show  a  reversed 
condition,  viz.,  that  in  the  case  of  twin  births  the  sexual  ratio  is 
lower  than  usual.  According  to  von  Prick's  collection  of  twin 
births  in  Prussia,  the  sexual  ratio  was  104.7  boys  to  100  girls; 
whereas  in  the  case  of  single  births  in  the  same  country  the  sexual 
ratio  was  106.35  to  Io°-  Riecke,  in  Wurttemberg,  in  the  case  of  60 
twin  births  found  58  boys  and  62  girls.  In  the  case  of  twin  births 
observed  by  Braun,  Chiari,  and  Spath,  94  in  all,  the  children  were 
in  64  of  these  of  identical  sexes,  namely,  in  30  instances  boys,  and 
in  34  instances  girls.  According  to  Breslau,  in  the  case  of  twin 
births  in  the  Canton  Zurich,  the  sexual  ratio  was  104.1  to  100; 
whereas  in  the  case  of  single  births  the  sexual  ratio  was  106.2 
to  loo. 

As  regards  triplets  the  reports  of  the  sexual  ratio  vary  from 
111.76:100  (Meckel  von  Hemsbach)  to  104.55:100  (Neefe). 

It  is  obvious  that  the  statistical  data  at  present  available  re- 
garding the  sexual  ratio  in  the  case  of  multiple  births  are  far  too 
variable  for  it  to  be  possible  to  bas.e  upon  them  any  valid  conclu- 
sions as  to  the  influence  of  the  nutritive  condition  of  the  mother 
upon  the  determination  of  the  sex  of  the  offspring.  And  taken  as  a 


THE  SEXUAL  EPOCH  OF  THE  MENACME.  439 

whole  the  statistical  data  hitherto  available  do  not  enable  us  to  infer 
with  confidence  that  nutritive  conditions,  and  more  especially  the 
nutritive  state  of  the  maternal  organism,  exercise  any  effect  upon 
the  determination  of  the  sex  of  the  offspring. 

Another  attempt  at  the  utilization  of  statistics  has  been  to  as- 
certain whether  the  time  of  fertilization  in  relation  to  menstruation, 
(in  the  first  days  after  the  flow,  or  later  in  the  intermenstrual  in- 
terval) has  any  influence  upon  the  determination  of  sex.  The 
starting  point  in  this  investigation  was  the  earlier  view  that  sex 
depends  upon  the  state  of  the  ovum,  and  the  belief  that  a  very 
favourable  state  of  ovum  and  sperm  favours  the  production  of  the 
female  sex.  The  ovum,  after  its  discharge  from  the  ovary,  like 
the  spermatozoon  after  its  discharge  from  the  testicle,  tends  sooner 
or  later  toward  death,  and  the  only  thing  that  can  save  either  from 
this  ultimate  fate,  is  for  the  two  to  unite  to  form  a  new  organism. 
Precisely  what  moment  in  the  history  of  the  detached  ovum  is  the 
most  favourable,  is  a  matter  regarding  which  we  have  no  exact 
information,  but  it  is  probable  that  at  the  moment  of  its  discharge 
from  the  ruptured  follicle,  it  is  at  the  zenith  of  its  vital  powers. 
On  this  theory  the  determination  of  sex  depends  upon  the  period  at 
which,  after  its  liberation  from  the  follicle,  the  ovum  encounters 
a  spermatozoon ;  the  ovum  which  is  fertilized  early  in  its  career 
becomes  a  female  embryo ;  the  ovum,  on  the  other  hand,  which  is 
not  fertilized  until  it  has  become  comparatively  old,  becomes  a  male 
embryo.  But,  as  Hcnscn  points  out,  a  spermatozoon,  according  to 
its  condition,  may  either  fail  sufficiently  to  fortify  an  ovum  which 
itself  is  in  good  condition;  or,  on  the  other  hand,  a  powerful 
spermatozoon  may  fortify  an  ovum  of  deficient  vitality.  But  it  is 
difficult  to  say  precisely  on  what  considerations  the  greater  or  less 
vitality  of  the  spermatozoon  depends  —  or,  to  speak  more  in  ac- 
cordance with  the  terms  of  the  theory,  we  do  not  know  exactly  what 
makes  it  a  good  spermatozoon  or  the  reverse.  It  may  be  "  bad," 
either  because  it  has  remained  too  long  in  the  testicle  or  because  it 
has  been  discharged  too  quickly,  is  too  recently  secreted ;  moreover, 
a  long  sojourn  of  the  spermatozoon  in  the  uterus  will  doubtless 
suffice  to  lower  its  vitality. 

The  Jews,  more  especially,  whose  religious  ordinances  forbid 
them  to  have  sexual  intercourse  either  during  or  shortly  after  men- 
struation, and  among  whom  there  is  a  great  excess  of  male  births, 
have  been  adduced  as  a  proof  of  the  thesis  that  sexual  intercourse 


44O  1HE    bEXUAL    LIFE    OF    WOMAN. 

during  the  later  part  of  the  intermenstrual  interval  tends  to  favour 
the  procreation  of  boys.  In  Leviticus  xv.  19,  we  read:  "And  if 
a  woman  have  an  issue,  and  her  issue  in  her  flesli  be  blood,  she 
shall  be  put  apart  seven  days."  From  the  commentary  in  the  Tal- 
mud it  appears  that  these  seven  days  are  to  be  reckoned  from  the 
commencement  of  the  flow.  Statistical  reports  from  various  coun- 
tries show  that  among  the  Jews  there  is  a  greater  excess  of  male 
births  than  among  the  other  inhabitants  of  the  respective  countries. 
The  overplus  of  male  births  exhibited  by  the  Jews  varies  from  I 
to  15$,  the  difference  probably  depending  on  the  fact  that  the  num- 
ber of  instances  under  consideration  is  too  small  for  uniform 
results  to  be  possible.  In  Prussia,  during  the  period  1820  to 
1834,  the  sexual  ratio  among  the  Jewish  births  was  ill  :ioo;  dur- 
ing the  period  1849  t°  1852  it  was  106:100;  in  Hungary  during 
the  period  1835  to  1855  it  was  117.1:100;  in  Sweden,  1851  to  1855, 
it  was  108:100.  Among  illegitimate  children  of  the  Jewish  com- 
munity the  sexual  ratio  was,  in  Austria,  123.9,  m  Prussia,  118.6. 

Fiirst,  examining  the  cases  in  von  Braun's  clinic,  and  making  a 
statistical  collection  of  the  days  of  conception  and  of  delivery,  has 
endeavoured  to  prove  that  "  there  is  an  excess  of  boys  when  con- 
ception occurs  during  the  period  of  post-menstrual  anaemia."  His 
figures  show,  in  fact,  a  very  notable  excess  of  boys  in  cases  in 
which  conception  has  occurred  during  the  five  days  immediately  fol- 
lowing the  cessation  the  menstrual  flow;  and  an  excess  of  girls 
when  conception  has  occurred  during  the  later  part  of  the  inter- 
menstrual  interval.  Thus,  in  the  former  case  the  excess  of  boys 
is  represented  by  the  figures  37:12;  in  the  latter  case  the  excess  of 
girls  is  represented  by  the  figures  79  (girls)  :  65  (boys).  These 
figures  are  explained  by  Fiirst  on  the  theory  that  in  the  human 
species  conception  during  the  period  of  post-menstrual  anaemia 
probably  leads  to  an  enormous  excess  of  male  conceptions  (owing 
to  the  fact  that  the  unfertilized  ovum  is  badly  nourished  during  the 
days  just  before  conception)  ;  whereas  in  the  later  part  of  the 
intermenstrual  interval  the  better  nourishment  of  the  ovum  prob- 
ably leads  to  the  procreation  of  an  excess  of  girls  —  hypotheses 
which  are  based  on  a  quite  inadequate  number  of  instances.  Fiirst 
gives  the  following  table: 


THE  SEXUAL  EPOCH  OF  THE  MENACME. 


441 


MUMBER  OF   DAYS   BETWEEN   REPUTED 
.END  OF  MENSTRUATION  AND  REPUTED 
OCCURRENCE  OF  CONCEPTION. 

Number 
of  boys 
born. 

Number 
of  girls 
born. 

Boys 
and  girls 
together. 

i  

7 

i 

g 

2  

6 

* 

7  .  . 

e 

14 

4  

TC 

7 

18 

c.  . 

7 

6 

6  

C 

6 

1  1 

7  

6 

c 

1  1 

8  

1 

8 

10 

9  

4 

e 

10  

6 

10 

ii  

6 

• 

1  1 

12  

7 

6 

13  

4 

i 

14  

6 

e 

17 

15  

i 

2 

16  

2 

e 

7 

17  

2 

7 

e 

18  

7 

19  

i 

7 

20  

i 

2 

21  

i 

I 

2 

22  

4 

I 

23  ;  

I 

I 

24  

I 

I 

25  

2 

2 

26  

2 

2 

27  

I 

I 

28  

I  • 

I 

2 

31  

I 

-    i 

102 

91 

193 

Baust  gives  a  report,  based,  he  says,  upon  "  thoroughly  trust- 
worthy data,"  furnished  by  personal  friends,  regarding  14  cases, 
which  show,  in  his  opinion,  that  every  conception  occurring  in  a 
week  after  the  cessation  of  the  menstrual  flow  leads  to  the  birth  of 
a  girl ;  but  that  when  conception  occurs  on  the  fifth  or  sixth  day 
after  menstruation  the  result  varies  as  regard  sex.  Szvift,  from 
a  report  of  20  cases,  draws  the  conclusion  that  in  the  intermenstrual 
interval,  boys,  in  the  latter  part  of  the  interval  girls  are  conceived. 

The  influence  of  the  strength  of  menstruation  upon  the  determina- 
tion of  sex  has  also  been  studied  by  the  statistical  method,  start- 
ing with  the  idea  that  menstruation,  in  proportion  to  its  strength, 
affords  on  the  average  a  measure  for  the  subsequent  nutrition  of 
the  embryo,  and  this  nutrition  is  further  supposed  to  determine  the 


442 


THE  SEXUAL  LIFE  OF  WOMAN. 


sex.  Dilsing  therefore  arranged  the  births  occurring  in  the  lying-in 
hospitals  of  Dresden,  Leipzig  and  Jena,  according  to  the  infor- 
mation given  regarding  menstruation  in  the  clinical  history  of  each 
case ;  it  appeared  that  when  menstruation  was  comparatively  scanty, 
there  was  a  greater  excess  of  boys  than  when  menstruation  was 
comparatively  abundant.  The  actual  figures  were  the  following: 


Abundant 
menstrua- 
tion. 

Scanty 
menstrua- 
tion. 

Dresden  

002     847 

4Q<»         4.31 

Jena  

66        69 

c6            4C 

Leipzig  

21            22 

2  3Q          211 

Totals  

98.)        9^8 

7QO          68? 

Sexual  ratio  

IQf  .  4 

II4.7 

Here  also  we  may  append  the  figures  obtained  by  D  using  re- 
garding the  births  of  foals  at  the  Prussian  stud-farms,  which  he 
regards  as  supporting  his  view  that  by  natural  selection  all  animals 
have  acquired  the  faculty,  whenever  stronger  demands  are  made 
upon  their  sexual  capacity,  of  procreating  a  larger  number  of 
individuals  of  their  own  sex.  In  the  tables  we  learn  how  many 
mares  on  an  average  a  stallion  had  covered  in  each  year,  that  is, 
we  learn  how  great  were  the  demands  made  upon  the  sexual  capa- 
city of  the  stallion  in  that  particular  breeding  stable  in  that  year. 
The  figures  relating  to  the  years  1859  to  1892  were  tabulated  and 
averages  were  drawn  with  the  following  results: 


NUMBER  OF  MARES  SERVED. 

NUMBER  OF  FOALS 
BORN. 

Sexual 
ratio. 

Colts. 

Fillies. 

60—70  .  . 

42,445 
56,5n 
59.940 
57.077 
59.967 
38.348 
26,354 

4i,933 
66  ,  226 
61  ,096 
59,216 
62  ,007 
40  ,  181 
27  ,069 

IOI  .  22 

100  .  49 
98.  18 

96-39 
96.71 

95-44 
97-35 

CC—  CO  .   . 

c,o—  c,4  .  . 

4?—  40  .  . 

40—44  

•7  C—  2Q  .   . 

20—34  .  . 

THE  SEXUAL  EPOCH  OF  THE  MENACME. 


443 


From  these  figures,  which  relate  a  very  large  number  of  instances 
indeed,  we  learn  that  when  greater  demands  are  made  upon  the 
stallion,  more  males  are  procreated.  In  fact,  except  for  two  slight 
divergencies,  the  rise  in  the  sexual  ratio  proceeds  strictly  pan  passu 
with  the  increase  in  the  number  of  mares  covered. 

I  must,  however,  draw  attention  to  the  fact  that  this  assumption 
when  applied  to  the  human  species,  that  the  man  on  whom  whose 
sexual  capacity  especially  extensive  demands  are  made,  procreates 
an  especially  large  number  of  male  children,  is  not  confirmed  by  the 
sexual  ratio  among  the  offspring  of  polygamous  marriages  in 
which  unquestionably  greater  demands  are  made  upon  the  husband's 
sexual  powers  than  is  the  case  in  monogamic  unions. 

The  reports  of  travellers  of  earlier  days,  to  the  effect  that  in 
Oriental  countries  more  girls  are  born  than  boys,  have  recently 
been  confirmed  by  several  observers.  Campbell  states  that  in  the 
harems  of  Siam  the  number  of  boys  and  girls  born  is  equal. 
Clarke  states  that  among  the  Mohammedan  Indians  more  girls  are 
born  that  boys.  According  to  McLennan  Indian  experience  teaches 
us  that  where  polyandry  prevails  male  offspring  predominate  in 
numbers;  but  where  polygamy  prevails  there  is,  on  the  contrary, 
an  excess  of  female  infants.  The  following  data  collected  by 
Gochlcrt  from  historical  reports  and  from  genealogical  writing's, 
regarding  the  progeny  of  notable  persons  living  in  polygamous 
unions,  show  certainly  a  large  excess  of  female  offspring  over  male : 


CHILDREN. 

Sexual 
ratio. 

Male. 

Female. 

Morocco  :  Muley  Scherif  

24 
28 
14 
no 

124 

60 
74 
128 

19.4 
46.6 
18.9 
85-9 

Palestine  :  Rehoboam,  King  of  the  Jews  . 
Arabia  :  Imon  of  Sana  

Turkey  :  nine  sultans  

|  ,  _  .  :  

According  to  Tousenel,  love  marriages  give  rise  to  more  daugh- 
ters than  sons,  whereas  among  the  offspring  of  conventional  or 
compulsory  marriages,  male  children  predominate.  Further,  among 
the  offspring  of  legitimate  unions,  the  excess  of  males  is  greater 
than  among  the  offspring  of  illegitimate  unions.  A  physician,  V.  /. 
Cook,  maintains  that  boys  are  procreated  in  the  evenings  (before 


444  THE  SEXUAL  LIFE  OF  WOMAN. 

midnight),  but  girls  during  the  early  morning  hours  —  at  which 
latter  time  women  are  less  "  impressionable  "  than  during  the  even- 
ing hours. 

D using,  starting  from  the  common  belief  that  all  animals  have  the 
faculty,  when  there  is  a  lack  of  individuals  of  one  sex,  of  pro- 
creating an  excess  of  offspring  of  the  sex  which  is  deficient  and 
thus  of  restoring  the  balance  between  the  sexes,  maintains  that 
numerous  factors,  through  the  co-operation  of  which  the  sexual 
ratio  is  regulated,  act  in  temporal  succession.  He  shows  that  the 
individuality  of  the  mother  has  an  influence  upon  the  sex.  But 
this  finds  expression  through  the  qualitative  constitution  of  the 
ovum;  hence  already  before  fertilization  there  must  exist  a  tend- 
ency toward  the  development  of  one  sex  or  the  other  —  for  example, 
younger  ova  tend  to  become  females;  older  ova,  on  the  contrary, 
to  become  males.  It  has  further  been  shown  that  the  individuality 
of  the  father,  that  is  to  say,  the  qualitative  constitution  of  the 
sperm,  has  an  influence  in  the  determination  of  sex.  Thus,  by 
means  of  the  influence  of  the  sperm,  the  already-mentioned  pre- 
existing tendency  of  the  ovum  can  in  some  instances  be  counteracted 
and  overpowered.  The  influences  in  the  personality  of  the  father 
and  of  the  mother,  which  during  fertilization  find  expression  in  the 
qualitative  constitution  of  the  sperm  and  of  the  ovum,  respectively, 
can  thus  bring  about  a  resultant  tendency,  acting  in  one  direction 
or  the  other  with  varying  force.  Thus,  after  fertilization,  we  have 
this  resultant  tendency  toward  the  formation  of  a  male  or  female 
embryo. 

But,  During  continues,  at  this  time  the  sex  is  not  definitely  de- 
termined. The  influence  of  the  nutritive  condition  in  which  the 
fertilized  ovum  finds  itself  has  yet  to  make  itself  felt.  .  This  in- 
fluence on  the  determination  of  sex  through  the  maternal  nutrition, 
continues  (in  the  human  embryo)  for  as  long  as  three  months,  but 
even  when  the  reproductive  organs  of  the  embryo  have  definitely 
begun  to  diverge  in  the  direction  of  the  masculine  or  the  feminine 
type,  as  the  case  may  be,  some  nutritive  influence,  if  it  is  sufficiently 
powerful,  may  yet  turn  the  balance  in  the  other  direction,  so  that  a 
partial  or  complete  hermaphrodite  results,  a  being  uniting  the  char- 
acteristics of  both  sexes. 

Actual  inheritance  of  sex,  of  which  people  used  to  speak,  cannot, 
in  D  Using' s  opinion,  possibly  occur.  The  mode  in  which  one  sex 
or  the  other  develops  is  indeed  inherited;  but  the  decision  which 
sex  shall  develop  does  not  depend  upon  inheritance,  but  is  deter- 


THE  SEXUAL  EPOCH  OF  THE  MENACME.  445 

mined  by  the  co-operation  of  several  outward  influences.  The 
qualities  by  which  this  is  effected  are  acquired  by  adaptation  to 
general  or  special  vital  conditions. 

Wilckens  ("A  study  of  the  Sexual  Ratio  and  of  the  Causes  of  the 
Determination  of  Sex  in  Domestic  Animals")  opposes  the  views 
of  Diising,  on  account  of  the  results  of  his  own  investigations,  re- 
lating to  the  births  of  30,000  domestic  animals.  He  formed  the 
following  conclusions : 

1.  Locality  (soil  and  climate)  has  an  influence  upon  the  sexual 
ratio  and  upon  the  determination  of  sex  in  domestic  animals,  but 
this  influence  is  probably  indirect  only,  being  exerted  through  the 
intermediation  of  the  nutrition  of  the  embryo  in  utero. 

2.  The  season  in  which  the  domestic  animal  is  conceived  affects 
the  sex;  the  hot  season  favours  the  production  of  males,  the  cold 
season  that  of  females;  in  the  hot  season,  in  general,  the  appetite 
and  nutrition  of  domestic  animals  diminish,  whereas  in  the  cold 
season  these  increase. 

3.  Regarding  the  male  progenitor,  neither  his  age,  nor  his  sexual 
energy,  nor  the  demand  made  upon  that  energy,  nor  the  age  of  the 
semen,  has  any  influence  upon  the  sexual  ratio  or  the  determina- 
tion of  the  sex  of  the  offspring. 

4.  The  age  of  the  female  progenitor  influences  the  sexual  ratio 
and  the  determination  of  the  sex  of  the  offspring  in  this  way,  that 
in  general,  primiparae  and  young  mothers  conceive  a  larger  number 
of  female  offspring.  This  influence  of  age  may  be  referred  to  the 
fact  that  in  general  young  mothers  nourish  their  offspring  in  utero 
better  than  older  mothers. 

5.  The  nutrition  of  the  fruit  in  utero  influences  the  determination 
of  sex,  speaking  generally,  in  the  following  way,  that  better  nutri- 
tion favours  the  determination  of  the  female  sex,  worse  nutrition 
favours  the  determination  of  the  male  sex. 

6.  In  addition  to  the  influence  of  nutrition  of  the  fruit  upon  the 
determination  of  sex,  other  influences,  whose  nature  still  remains 
obscure,  must  also  co-operate,  because  one  and  the  same  progenitor 
in  similar  nutritive  conditions  does  not  always  procreate  offspring 
of  the  same  sex. 

7.  Owing  to  the  operation  of  these  unknown  influences,  predic- 
tion of  the  sex  of  the  offspring,  and  voluntary  determination  of  the 
sex  of  the  offspring,  remain  impossible.     All  we  can  say  is  that 
there  is  some  probability  that  young  and  well-nourished  mothers 
will  procreate  a  comparatively  larger  .number  of  female  offspring, 


446  THE  SEXUAL  LIFE  OF  WOMAN. 

whilst  elderly  and  ill-nourished  mothers  will  procreate  a  compara- 
tively larger  number  of  male  offspring. 

//.  Anatomical  Investigations. 

Of  anatomical  investigations  and  discoveries,  those  more 
especially  relating  to  the  sex-relationships  of  twins  and  triplets  have 
been  applied  to  the  elucidation  of  the  problem  of  the  determination 
of  sex. 

The  first  and  most  important  fact  in  this  connection,  one  that  is 
not  merely  a  rule  confirmed  again  and  again  by  anatomists  and 
gynecologists,  but  is  further,  as  Mayrhofer  has  demonstrated  as  a 
result  of  his  researches  in  von  Brann's  clinic,  a  "  natural  law,"  is 
this,  that  twins  and  triplets  enclosed  in  a  common  chorion  are 
invariably  of  the  same  sex.  The  sex-identity  of  such  twins  has 
been  referred  to  the  similarity  of  their  nutritive  conditions 
(Leuckart,  Ploss),  and  more  especially  to  the  communication  be- 
tween their  bloodvessels ;  and  an  intimate  connection  between  these 
relationships  and  the  determination  of  sex  has  been  believed  to 
exist. 

Mayrhofer,  however,  opposes  this  assumption  by  the  following 
deductions  ("The  Determination  of  Sex  in  the  Human  Species")  ; 
"  Foetuses  enclosed  within  a  single  chorion  always  possess  a  com- 
mon placenta,  in  which  the  blood-channels  from  both  umbilical  cords 
frequently,  in  the  case  of  twins  perhaps  invariably,  communicate. 
It  might  therefore  be  supposed  that  the  sex-identity  of  embryos 
enclosed  within  a  single  chorion  is  due  to  the  intermixture  of  their 
blood  in  the  placenta.  Hyrtl,  however,  describes  a  triplet's  placenta, 
in  which,  though  all  three  foetuses  were  enclosed  within  a  single 
chorion,  the  vessels  passing  to  the  umbilical  cord  of  one  of  the 
foetuses  were  entirely  distinct  from  the  vascular  area  common  to. 
the  two  other  foetuses ;  it  is  therefore  probable  that  in  the  case  also 
of  twins  enclosed  within  a  single  chorion  there  is  not  necessarily 
any  communication  between  their  bloodvessels  in  the  common 
placenta.  But  even  if  it  were  proved  that  in  the  case  of  twins  en- 
closed within  a  single  chorion  their  bloodvessels  always  do  com- 
municate in  the  common  placenta,  we  could  not  therefore  infer  that 
the  intermixture  of  the  blood  of  the  two  foetuses  is  the  cause  of 
their  sexual  identity. 

"  For  the  intermixture  of  the  blood  of  the  two  foetuses  in  the 
common  placenta  could  never  lead  to  a  complete  identity  in  the 
composition  of  the  blood  of  the  two;  it  could  only  lead  to  a  dimi- 


THE  SEXUAL  EPOCH  OF  THE  MENACME.  447 

nution  of  the  differences  which  would  exist  between  the  bloods  if 
their  placental  circulations  were  entirely  distinct,  and  the  similarity 
in  the  bloods  thus  established  could  not  be  expected  to  do  more 
than  make  it  a  general  rule  that  such  twins  or  triplets  should  be 
of  the  same  sex;  but  to  this  rule  exceptions  might  be  expected  to 
occur  in  certain  cases,  as  when  haematopoiesis  in  the  two  (or  three) 
foetuses  was  very  different,  or  when  the  circulation  through  the 
intercommunicating  bloodvessels  was  interfered  with  through  the 
pressure  of  fibrinous  deposits  —  differences  between  the  bloods 
would  then  arise  sufficient  to  cause  differences  in  sex  (if  identical 
composition  of  the  bloods  is  presumed  to  be  the  cause  of  the  sexual 
identity). 

"  Experience  teaches  us  that  the  existence  of  communicating  ves- 
sels in  the  placenta  does  not  suffice  to  induce  a  close  similarity  of 
growth  and  of  the  formation  of  the  organs  in  twin  foetuses;  nor 
does  it  prevent  the  illness  and  death  of  one  fcetus  leaving  the  health 
of  the  -other  undisturbed,  although  the  communicating  channels  re- 
main open ;  so  that,  if  we  except  acardiac  monsters,  it  is  correct  to 
say  that  each  foetus  pursues  a  secluded  life,  uninfluenced  by  the 
life  of  its  neighbour.  Acardiac  monsters,  on  the  other  hand,  al- 
ways receive  blood  which  has  already  served  for  the  nutrition  of  the 
normal  foetus,  and  the  result  of  this  is  an  arrested  development 
and  a  striking  preponderance  of  connective  tissue  in  the  acardiac 
twin.  But  notwithstanding  the  fact  that  the  failure  of  its  own 
proper  circulation  (which  is  indeed  rendered  possible  by  the  exist- 
ence of  the  communicating  vessels  in  the  placenta)  leads  to  its  de- 
fective nutrition  with  a  blood  inferior  to  that  supplied  to  the  normal 
foetus,  the  acardiac  monster  is  always  of  the  same  sex  as  the  normal 
twin." 

From  these  considerations  Mayrhofer  rightly  infers  that  the 
identity  of  sex  of  two  foetuses  contained  in  a  single  chorion,  since 
it  does  not  depend  upon  the  existence  of  communicating  vessels  in 
the  placenta,  must  arise  from  a  developmental  tendency  already 
existing  in  the  two  germs  at  the  time  of  conception  —  or,  in  other 
words,  that  at  the  time  of  conception  their  sex  is  already  inalterably 
determined. 

This  conclusion  with  respect  to  the  sex  of  twins  contained  in  a 
single  chorion  may  very  readily  be  extended  to  the  inference  that 
in  the  case  of  all  human  foetuses  the  sex  is  already  determined  at 
the  time  of  conception. 

Another  anatomical  fact  is  that  many  twins  are  contained  in  a 


448 


THE  SEXUAL  LIFE  OF  WOMAN. 


single  chorion  for  this  reason,  that  they  originate  from  two  germinal 
vesicles  within  a  single  ovum.  It  is  an  open  question  whether  it  is 
not  possible  for  two  embryos  contained  in  separate  chorions  to 
come  to  lie  in  a  single  chorion  through  atrophy  of  the  intermediate 
wall.  If  this  is  indeed  possible,  the  invariable  identity  of  sex  in 
the  case  of  fetuses  lying  in  a  single  chorion  must  lead  us  to  agree 
with  Mayrhofer  in  inferring  that  two  ova  lying  within  a  single 
follicle,  simultaneously  fertilized,  give  rise  to  embryos  of  identical 
sex. 

B.  S.  Schultze  and  Ahlfeld,  as  a  result  of  the  investigations  re- 
garding twins,  also  came  to  the  conclusion  that  the  sexual  identity 
of  twins  depends  upon  their  derivation  from  a  single  ovum.  If,  in 
accordance  with  what  has  been  said  above,  an  explanation  of  the 
sexual  identity  of  certain  twins  is  to  be  found  in  the  fact  that  for 
such  twins  there  has  been  a  single  conception  only,  and  hence  the 
influence,  whatever  it  may  be,  by  which  sex  is  determined  acts  on 
both  germs  at  the  same  time — still  the  sexual  identity  of  twins  in 
general  is  remarkable  and  has  not  yet  been  fully  explained.  The 
sexual  identity  in  fact  occurs  much  more  frequently  than  appears 
to  correspond  to  the  percentage  of  twins  derived  from  a  single 
ovum.  Von  Pricks  examined  the  data  relating  to  multiple  births 
in  Prussia  during-  the  period  of  1826  to  1879  and  compiled  the 
following  table : 


PER  CENT. 

Twins. 

Triplets. 

Qua- 
druplets. 

Quin- 
tuplets. 

Boys  only  

72     6 

24     ? 

Girls  only  

TO     -I 

22     C 

Boys  and  girls  

77     I 

c-2     o 

66    i 

66   7 

2  B.  i  G. 
i  B.  2  G. 

28.5 
24-5 

2    B.    2   G. 

3  B.  i  G. 
i  B.  3  G. 

23-4 
19-5 
23-4 

- 

4  B.  i  G. 
3  B.  2  G. 

33-3 
33-3 

According  to  Ahlfeld,  of  twin  births  in  general,  the  ratio  of  those 
with  a  common  chorion  to  those  with  separate  chorions  is  T  :  8.15. 
Jf,  however,  we  wished  to  explain  the  frequency  with  which  twins 


THE  SEXUAL  EPOCH  OF  THE  MENACME.  449 

are  of  identical  sex  from  the  occurrence  of  such  twins  derived  from 
a  single  ovum,  we  should  expect  to  find  a  very  different  ratio, 
namely,  i :  3.84 ;  that  is  to  say,  twins  with  a  common  chorion  would 
have  to  be  nearly  three  times  as  common  as  they  actually  are. 
From  these  facts  Diising  endeavours  to  draw  the  conclusion  that 
external  conditions  have  an  influence  upon  the  determination  of 
sex,  for  very  many  external  conditions  are  identical  in  the  case  of 
twins ;  as,  for  instance,  the  age  of  the  father,  the  age  of  the  mother, 
the  nutritive  conditions  of  the  ova  and  of  the  spermatozoa,  the 
nutrition  of  the  embryo,  etc. —  all  of  these  would  influence  both  the 
twins  in  the  same  direction.  A  difference  in  the  sex  of  twins,  on 
the  other  hand,  might  be  due  to  two  successive  fertilizations. 

B.  S.  Schultze  has  been  led  by  his  embryological  studies  to  the 
conclusion  that  there  are  male  and  female  ova.  Thus  he  believes 
that  sexually  identical  twins  originate  from  a  single  ovum  with  two 
germinal  vesicles,  thus  assuming  that  a  double  fertilization  of  such 
ova  is  possible.  But  since  in  such  cases  the  sexes  of  the  resulting 
twins  are  always  identical  the  spermatozoon  can  have  no  influence 
upon  the  determination  of  sex,  but  the  conditions  leading  to  the 
development  of  one  sex  or  the  other  must  pre-exist  in  the  ovum  — 
i.  c.,  there  must  be  male  and  female  ova. 

That  as  a  matter  of  actual  fact  in  some  cases  the  female  progeni- 
tor exercises  an  overwhelming  influence  on  the  determination  of 
sex,  and  that  the  opinion  held  by  so  many  that  this  determination 
depends  upon  the  mother  alone  is  sometimes  supported  by  facts,  is 
shown  by  the  incident  recorded  by  Darwin  ("Descent  of  Man," 
Vol.  I.),  that  an  Arab  mare  was  delivered  seven  times  successively 
of  a  filly,  never  of  a  colt,  although  she  was  covered  by  seven  differ- 
ent stallions.  On  the  other  hand,  the  circumstance,  if  it  is  not  to 
be  attributed  to  pure  chance,  can  also  be  explained  by  the  consti- 
tutional vigour  of  this  mare  (Hensen)  without  adopting  the  above 
hypothesis. 

Recently  Upjohn  has  maintained  that  there  are  two  kinds  of 
spermatozoa,  male  and  female;  the  latter  are  the  commonest,  but 
the  former  are  the  more  energetic. 

An  interesting  anatomical  fact  bearing  upon  this  question  has 
been  discovered  by  M.  Nussbaum,  namely,  that  in  ascaris  megalo- 
cephala  the  reproductive  glands  are  indicated  already  before  the 
separation  of  the  germinal  layers ;  and  Nussbaum  suggests  that  this 
is  also  the  case  in  all  animals,  although  the  proof  cannot  be  obtained 
in  every  instance. 

29 


450  THE  SEXUAL  LIFE  OF  WOMAN. 

Semper  has  shown  also  in  the  case  of  some  of  the  plagiostomata 
that  long  before  the  beginning  of  the  definitive  development  of  the 
reproductive  organs,  the  apparently  hermaphrodite  embryo  already 
possesses  at  least  the  tendency  toward  the  constitution  of  one  sex 
or  the  other.  For  in  these  animals,  at  a  time  so  early  that  as  yet 
the  reproductive  glands  exhibit  no  sexual  differentiation  whatever, 
the  sexes  can  nevertheless  be  distinguished  by  what  appears  to  be  a 
secondary  sexual  character.  In  the  female,  namely,  one  ovary  only 
is  developed ;  and  very  early  indeed  in  the  embryos  destined  to 
become  females  we  can  observe  an  asymmetrical  development  of 
the  two  germinal  furrows.  By  this  characteristic  the  two  sexes  can 
be  distinguished  far  earlier  than  it  is  possible  to  do  so  by  the  recog- 
nition of  a  histological  differentiation  of  the  reproductive  glands. 

According  to  Mayrhofcr  the  prepotency  of  the  male  gives  rise 
to  the  procreation  of  an  excess  of  males  in  this  way,  that  physical 
prosperity  of  the  male  probably  leads  to  the  generation  of  boys, 
whereas  prosperity  of  the  female  tends  to  give  rise  to  the  genera- 
tion of  girls.  Moreover,  economizing  of  the  semen  by  infrequent 
sexual  intercourse  tends  to  originate  offspring  of  the  male  sex.  In 
this  connection  Hensen  remarks,  apropos  of  the  greater  excess  of 
male  offspring  among  the  Jews :  "  We  might  ask  whether,  in  con- 
sequence of  the  comparative  sexual  continence  of  the  Jews  which 
demands  a  definite  power  of  endurance  on  the  part  of  the  ova, 
there  may  not  be  effected  a  certain  selection  of  the  ova;  and  thus 
we  may  perhaps  explain  how  it  is  that  in  this  race  an  exceptional 
vigour  is  somewhat  more  often  to  be  observed  than  in  other  races." 
Bock  assumes  that  "  thinner  semen,"  such  as  results  from  more 
frequent  sexual  intercourse,  favours  the  procreation  of  the  female 
sex,  whereas  when  intercourse  is  less  frequent  a  larger  number  of 
boys  is  likely  to  be  born.  Janke  indicates  as  two  important  funda- 
mental principles  of  scientific  physiology  that,  (i)  sexual  inter- 
course represents  as  it  were  a  contest  between  the  two  parties  to 
the  sexual  act  as  to  which  shall  transmit  his  or  her  sexual  influence 
to  the  child,  the  victor  in  the  contest  determining  the  sex  of  the 
offspring,  and  (2)  that  a  crossed  inheritance  occurs,  inasmuch  as 
whichever  progenitor  proves  stronger  in  this  contest  transmits  to 
the  child  the  sex  other  than  his  or  her  own.  He  therefore  advises 
women  who  long  to  have  a  boy  to  drink  a  glass  of  champagne  before 
fulfilling  their  conjugal  duties  in  order  to  gain  increased  sexual 
vigour. 

Piquet  also  expresses  the  opinion  that  when  a  vigorous,  passion- 


THE  SEXUAL  EPOCH  OF  THE  MENACME.  451 

ate,  and  sanguine  male  progenitor  has  intercourse  with  a  frigid  and 
phlegmatic  woman  there  will  be  a  preponderant  tendency  for  the 
offspring  to  be  female ;  whereas,  when  the  conditions  are  the  oppo- 
site of  these,  the  male  progenitor  being  phlegmatic  and  cold,  the 
female  on  the  contrary  sanguine,  passionate,  and  ardent,  the  off- 
spring will  probably  be  of  the  male  sex. 

In  opposition  to  these  opinions  of  Piquet  and  Janke,  to  the  effect 
that  the  temperament  and  the  sexual  vigour  of  the  progenitors  have 
a  determining  influence  in  the  origination  of  the  sex  of  the  off- 
spring, D using  insists  that  the  quality  of  the  reproductive  products 
are  alone  influential.  Diising  lays  down  the  following  proposition: 
"  The  greater  the  scarcity  of  individuals  of  one  sex  is,  the  more 
extensive  consequently  the  demands  made  upon  the  sexual  capacities 
of  the  individuals  of  that  sex,  the  more  rapidly  their  reproductive 
products  are  employed;  and  the  younger  these  products  therefore 
are  when  employed  the  more  individuals  of  their  own  sex  will 
appear  among  the  offspring." 

Richarz  believes,  on  the  contrary,  that  the  prepotency  of  the  male 
gives  rise  to  the  procreation  of  more  girls;  a  mother  of  high  repro- 
ductive capacity  will  have  more  boys,  one  of  less  reproductive 
capacity,  on  the  other  hand,  more  girls. 

Starkzveather  ("  The  Law  of  Sex,"  London,  1883)  states  his  view 
in  the  proposition :  "  The  superior  parent  produces  the  opposite 
sex ;"  and  he  holds  the  quaint  view  that  this  superiority  is  displayed 
in  certain  anatomical  characters  of  the  face  of  the  progenitor.  He 
endeavours  from  the  shape  of  the  head  and  from  the  facial  ex- 
pression to  deduce  the  superiority  of  the  male  and  the  female  pro- 
genitor respectively.  A  high,  square  forehead,  with  prominent 
supra-ciliary  ridges,  constitutes,  according  to  Starkweather,  one  of 
the  principal  symptoms  of  this  superiority ;  important  also  are  a 
strongly  developed  middle  third  to  the  nose,  narrow  lips,  etc.  He 
declares  that  in  families  known  to  him  the  possession  of  this  Roman 
nose  in  the  father  is  signalized  by  the  possession  also  of  a  large 
number  of  daughters,  while  a  Roman-nosed  mother  has  many  sons. 
The  more  the  parents'  noses  resemble  each  other  the  more  equal 
will  be  the  distribution  of  the  sexes  among  the  offspring.  He  con- 
nects this  fact  (  !)  also  with  the  fact  that  the  possessor  of  the 
aquiline  nose  is  the  ruler  of  the  family.  Men  of  great  strength  of 
character  procreate  chiefly  daughters ;  women,  on  the  other  hand, 
with  a  powerful  character  and  a  firm  will  bring  into  the  world  a 
notable  excess  of  boys.  In  the  Southern  States  of  the  American 


452  THE  SEXUAL  LIFE  OF  WOMAN. 

union  Starkweather  found  confirmation  of  his  theory,  since  he  ob- 
served there  that  among  the  offspring  of  white  fathers  and  coloured 
mothers  there  was  an  excess  of  girls  amounting  to  12  to  15  per  cent. 
Among  the  half-castes,  of  Java,  the  so-called  Lipplapps,  in  the  third 
generation  girls  only  are  born,  and  these  are  sterile.  The  excess 
of  girls  in  these  cases  depends  upon  the  superiority  of  the  white 
father;  this  superiority  is  transmitted  to  the  few  sons  of  the  second 
generation,  and  these  therefore  procreate  girls  only  to  constitute 
the  third  generation;  the  latter  are  not  powerful  enough  to  bear 
children  at  all. 

Roth  has  revived  the  old  view  that  one  ovary  provides  the  germs 
for  the  male  offspring,  the  other  those  for  the  female  offspring.  He 
believes  further  that  in  the  process  of  cohabitation  the  mechanical 
impressions  and  stimuli  received  by  one-half  of  the  external  genital 
organs,  reinforced  by  contact  with  and  pulling  on  the  pubic  hair, 
are  transmitted  through  the  pudic  nerve  and  the  hypogastric  plexus 
to  the  corresponding  half  of  the  vagina  and  the  uterus,  to  the 
Fallopian  tube  of  that  side  and  to  the  corresponding  ovary.  If,  now, 
we  can  consider  it  as  established  (?),  that  in  the  human  female 
one  ovary  discharges  male  ova  only  and  the  other  female  ova  only, 
it  seems  to  him  that  it  is  the  corresponding  half  of  the  external 
genital  organs,  when  specifically  stimulated  in  sexual  intercourse, 
and  the  consequently  increased  vital  activity  in  the  pudic  nerve  and 
its  connections  with  the  hypogastric  plexus,  that  must  be  regarded 
as  the  organ  by  means  of  which  sex  is  determined.  Roth  has  also 
been  informed  by  laymen  that  when  for  some  time  they  have  pro- 
created daughters  only  they  subsequently  procreated  sons,  "  when, 
having  been  accustomed  to  sleep  on  one  side  of  their  wife,  they 
adopted  the  practice  of  sleeping  on  the  other." 

Ricardi  reports  that  in  Modena  the  peasants  say  that  a  man  whose 
wife  has  hitherto  had  daughters  only,  must,  if  he  wishes  to  have  a 
son,  assume  some  other  posture  than  usual  in  the  performance  of 
coitus. 

///.  Experimental  Investigations. 

A  considerable  number  of  years  ago,  Thury  attacked  the  problem 
of  the  determination  of  sex  by  the  experimental  method.  In  his 
series  of  experiments  he  ascertained,  using  29  cows,  that  in  the 
case  of  22  of  these,  which  were  served  early  in  their  heat,  the  calves 
were  without  exception  heifers,  while  in  the  case  of  the  remain- 
ing 7,  which  were  served  late  in  their  heat,  the  calves  were  equally 


id   H 


THE  SEXUAL  EPOCH  OF  THE  MENACME.  453 

without  exception  bull-calves  (Thury,  "  The  Law  of  the  Determina- 
tion of  the  Sexes,"  Leipzig,  1863)  ;  in  the  record  of  these  experi- 
ments no  mention  is  made  of  the  age  of  the  cows.  Thirty  concluded 
that  the  sex  was  determined  according  to  the  fertilization  of  the 
ovum  soon  or  late  after  its  liberation  from  the  ovary ;  namely,  that 
an  ovum  fertilized  soon  after  its  discharge  produced  a  female, 
whilst  an  ovum  which  had  become  comparatively  old  before  it  was 
fertilized  became  a  male. 

Thury' s  sensational  experiments  gave  rise  to  a  succession  of  simi- 
lar experiments,  made  mostly  by  cattle-breeders,  above  all  in  agri- 
cultural colleges  and  in  stud-farms. 

Some  of  these  experiments  were  made  in  the  agricultural  col- 
leges at  Proskau  and  Eldera.  The  cows,  which  according  to 
Thury' s  views  should  have  been  delivered  of  heifers,  were  served 
as  soon  as  their  heat  was  observed  (the  heat  lasted  as  a  rule  from 
24  to  30  hours)  ;  these  were  delivered  of  5  heifers  and  5  bull-calves 
(in  Proskau)  and  of  3  heifers  and  5  bull-calves  (in  Eldera)  ;  the 
sexual  ratio  in  these  cases  was  therefore  normal.  On  the  other 
hand,  cows  which  were  not  served  until  their  heat  had  lasted  for 
20  hours  were  delivered  (in  Proskau)  of  I  heifer  and  4  bull-calves. 

Further  experiments  (in  Waldau)  gave  the  result  that  cows 
served  early  were  delivered  of  I  heifer  and  I  bull-calf.  In  another 
series  (in  Eldera)  9  cows  served  as  soon  as  heat  was  observed  (or, 
speaking  strictly,  in  from  ^  to  il/2  hours  of  this),  gave  birth  to 
7  heifers  and  2  bull-calves. 

Experiments  made  at  the  Royal  Friedrich  Wilhelm  Stud-Farm 
gave  the  following  results :  In  the  case  of  20  mares,  which  if 
Thury's  theory  had  been  correct  should  all  have  given  birth  to 
fillies,  ii  only  fulfilled  this  expectation;  but  10,  on  the  other  hand, 
were  colts.  Toiichon,  in  his  experiments  at  Hohenhau,  obtained 
ii  calves  and  2  foals,  exhibiting  the  sex  expected  in  accordance 
with  Thury's  theory. 

D using  made  a  compilation  of  the  figures  given  in  all  the  experi- 
ments made  to  test  Thury's  theory,  with  the  following  results: 
Cows  fertilized  early  were  delivered  of  13  bull-calves  and  29  heif- 
ers; mares  fertilized  early  were  delivered  of  10  colts  and  13  fillies; 
cows  fertilized  late  were  delivered  of  5  bull-calves  and  2  heifers. 

Gcrbe  made  experiments  on  rabbits,  putting  the  buck  to  some 
doe-rabbits  soon  after  the  beginning  of  their  heat,  but  to  others  as 
late  as  possible  in  their  heat.  On  examining  the  young  in  the  horns 
of  the  uterus,  from  the  ovary  downward,  the  distribution  of  the 
sexes  was  found  to  be  approximately  equal. 


454  THE  SEXUAL  LIFE  OF  WOMAN. 

Whilst  Coste's  experiments  on  a  hen  gave  results  contradictory 
to  Thury's  theory,  Albini's  experiments,  made  also  on  the  common 
fowl,  gave  results  in  agreement  with  that  theory.  He  found  that 
the  hens  began  again  to  lay  fertilized  eggs  3  to  6  days  after  inter- 
course with  the  cock  (from  which  they  had  previously  been  kept 
separate)  ;  on  the  average,  the  distribution  of  the  sexes  in  the 
chickens  hatched  from  these  eggs  was  approximately  equal,  with, 
however,  a  slight  preponderance  of  cock  birds.  On  the  ninth  and 
tenth  days  after  separation  from  the  cock  the  eggs  laid  were  half 
fertilized  and  half  unfertilized ;  on  the  twelfth  day  after  separation 
from  the  cock  the  unfertilized  eggs  were  in  a  great  majority;  but 
even  as  late  as  the  eighteenth  day  after  separation  some  of  the  eggs 
laid  were  still  fertilized.  The  fertilized  eggs  laid  from  the  tenth  to 
the  fifteenth  day  after  separation  when  incubated  produced  a  great 
preponderance  of  hen  birds. 

We  have  to  thank  breeders  for  a  large  number  of  experiments, 
such  as  those  made  by  the  breeder  Piquet,  at  Houston  in  Texas, 
who  found  that  a  bull  upon  whose  sexual  capacities  excessive 
demands  were  made,  procreated  bull-calves  exclusively;  whereas  in 
herds  containing  numerous  bulls  there  were  found  among  the  calves 
born  a  preponderance  of  heifers.  In  thirty  experiments  on  cattle 
Piquet  always  found  that  the  larger  the  number  of  cows  a  bull  had 
to  serve,  and  the  longer  they  were  kept  in  service,  the  larger  was 
the  proportion  of  bull-calves  among  their  offspring.  On  the  other 
hand,  if  certain  cows  had  their  sexual  desires  first  satisfied  by  a 
gelded  animal  and  were  then  served  by  a  vigorous  and  lusty  bull, 
an  excessive  proportion  of  heifers  was  born  to  these  animals. 

Janke  obtained  similar  results  in  the  breeding  of  sheep.  In  a 
report  made  to  D using  he  states  that  in  the  early  part  of  the  lamb- 
ing season  more  ewe-lambs  are  born  than  rams;  in  the  latter  part 
of  the  lambing  season,  on  the  contrary,  more  rams  than  ewes.  The 
explanation  he  gives  is  that  at  the  commencement  of  the  pairing 
the  rams  are  fresh  and  lusty,  whilst  later  their  potency  is  com- 
paratively exhausted.  In  stud-farms,  according  to  the  same  ob- 
server, it  is  a  familiar  experience  that  the  most  vigorous  stallions 
serving  a  mare  in  the  morning  commonly  procreate  a  filly;  but  if 
later  in  the  day  they  serve  a  second  mare  they  almost  always  pro- 
create a  colt.  This,  he  thinks,  finds  its  explanation  in  the  fact  that 
the  stallion,  when  he  serves  the  second  mare,  is  in  a  condition  of 
comparative  sexual  exhaustion,  the  more  so  because  he  usually 
covers  the  first  mare  twice. 


THE  SEXUAL  EPOCH  OF  THE  MENACME.  453 

Maritegoute's  breeding  experiments  at  the  sheep-farm  of  Blanc 
(Haut-Garonne);  on  the  other  hand,  gave  divergent  results.  In 
the  early  part  of  the  pairing  season,  as  long  as  the  ram's  sexual 
powers  were  completely  unimpaired,  he  procreated  more  male  than 
female  lambs.  But  when  a  few  days  later  a  great  number  of  the 
ewes  were  simultaneously  on  heat  and  the  ram,  owing  to  very  fr£^ 
quent  acts  of  intercourse,  began  to  be  sexually  exhausted,  the  pro- 
creation of  female  lambs  was  in  excess.  But  when,  finally,  this 
period  of  maximum  demands  upon  the  ram's  powers  was  past, 
and  the  number  of  ewes  on  heat  became  once  more  small,  the  pro- 
creation of  male  lambs  in  preference  to  female  was  again  observed. 

The  data  obtained  by  D using  from  the  Prussian  stud- farms,  in 
which,  when  greater  sexual  demands  were  made  on  the  stallions, 
more  males  were  procreated,  have  been  already  mentioned. 

Fiquct  made  interesting  experiments  on  cows  and  believed  that 
in  this  way  he  was  able  to  demonstrate  the  influence  of  nutrition 
upon  the  determination  of  sex  —  to  such  a  degree,  indeed,  that  he 
believed  it  was  possible  to  breed  calves  of  either  sex  at  will.  The 
following  method  gave  him  positive  results  in  more  than  thirty  in- 
stances. He  never  had  the  cow  served  by  the  bull  at  the  first  heat, 
but  only  at  the  second  (if  a  cow  is  left  unserved  when  on  heat, 
the  heat  recurs  after  an  interval  of  three  weeks).  The  interval  of 
three  weeks  was  utilized  in  the  preparation  of  cow  and  bull  for  the 
copulatory  act.  If  a  bull-calf  was  wanted  the  cow  was  supplied 
•with  the  most  invigorating  fodder  and  was  kept  on  the  richest 
pasture  available.  The  bull,  on  the  other  hand,  that  was  to  serve 
this  cow  was  turned  out  to  graze  on  the  poorest  pasture  and  was 
given  poor  fodder..  At  the  end  of  the  three  weeks,  when  the  cow 
came  on  heat  for  the  second  time,  its  sexual  appetite  was  as  intense 
as  possible,  whereas  the  bu|J  showed  but  slight  inclination  to  the 
sexual  act.  If  the  buJJ  now  served  the  cow  a  bull-calf  was  pro- 
created. The 'opposite  procedure  led  to  the  procreation  of  a  heifer. 
For  this  purpose  Piquet  kept  the  cow  on  low  diet  during  the  interval 
ibetweea  the  first  and  second  heats,  and  had  her  first  served  by  a 
castrated  animal.  When  in  this  way,  and  by  the  low  diet,  the 
sexual  appetite  of  the  cow  had  been  sufficiently  diminished,  it  was 
served  by  a  lusty  bull,  which  for  a  long  time  had  not  been  put  to 
any  cow.,  and  the  sexual  potency  of  which  had  been  increased  to 
the  uttermost  by  feeding  it  for  several  weeks  on  the  most  invigorat- 
ing fodder. 

The  results  of  these  experiments,  according  to  which  the  nutri- 


456  THE  SEXUAL  LIFET  OF  WOMAN. 

tion  of  the  parent-animals  before  the  copulatory  act  has  an  influ- 
ence upon  the  determination  of  sex,  is  explained  by  D using  in  this 
way,  that  nutrition  influences  also  the  quality  of  the  reproductive 
products.  "  Poor  nutrition  gives  rise  to  diminished  functional 
capacity  of  the  genital  apparatus.  Thus,  for  example,  the  produc- 
tion of  semen  is  lessened.  It  can,  in  fact,  hardly  be  replaced  as 
quickly  .as  it  is  used  up.  This  occurs  when  there  is  a  lack  of 
adequate  means  of  subsistence,  and  also  when  there  is  a  lack  of 
comparatively  young  males.  In  both  cases  alike  we  trace  the  effects 
in  the  birth  of  an  excess  of  males.  Converse  conditions  give  rise 
to  an  excess  of  female  offspring." 

Passing  now  to  consider  investigations  made  by  physiologists, 
Born,  at  the  anatomical  institute  at  Breslau,  has  endeavoured  to 
solve  the  problem  of  the  determination  of  sex  by  means  of  experi- 
ment. He  employed  for  this  purpose  rana  fusca,  an  animal  with 
which  positive  results  can  be  obtained  in  a  comparatively  short 
period  of  time.  He  examined  the  sex  both  of  the  frogs  in  the 
free  state  (165),  and  also  of  larvae  which  he  had  bred  in  specially 
arranged  aquaria.  Whereas  among  the  frogs  developing  in  the 
open,  the  numbers  of  the  sexes  appeared  to  be  approximately  equal 
(there  was  an  excess  of  females  amounting  to  2  or  3  per  cent.)  ; 
among  those  bred  in  the  aquaria  there  was  an  enormous  preponder- 
ance of  females  (96  per  cent.).  This  remarkable  result  is  referred 
by  Born  to  the  inadequate  supply  of  nutriment  in  the  case  of  the 
larvae  bred  by  him  (he  fed  them  on  hydrae  and  on  putrefying  frog 
and  tadpole  meat)  ;  from  an  examination  of  the  alimentary  canal 
of  tadpoles  caught  in  the  open  Born  ascertained  that  their  normal 
food  was  the  mud  of  the  pools  in  which  they  were  hatched,  con- 
taining infusioria,  radiolariae,  diatoms,  algae,  etc.  The  accuracy  of 
this  explanation  appeared  to  Born  to  be  more  convincingly  shown 
by  the  results  in  the  case  of  one  of  his  twenty-one  acquaria.  In  this 
one  alone  the  percentage  of  males  was  as  high -as  28  per  cent.,  and 
the  tadpoles  in  this  attained  the  same  size  as  those  developed  under 
natural  conditions  in  the  open,  whilst  in  all  the  other  aquaria  the 
tadpoles  remained  abnormally  small.  This  particular  aquarium, 
owing  to  an  oversight,  had  pond-mud  on  its  floor,  whilst  all  the 
other  aquaria  were  floored  with  clean  sand. 

A.  von  Gricshcim  disputes  Born's  results  and  believes  that  the 
latter,  determining  the  sex  of  the  tadpoles  by  means  of  a 
hand  lens,  must  have  mistaken  a  great  many  female  tadpoles  for 
males.  He  himself,  by  repeated  enumerations  of  a  large  number 


THE  SEXUAL  EPOCH  OF  THE  MENACME.  457 

of  tadpoles  (685),  part  caught  in  the  open  and  part  taken  from  a 
large  aquarium,  found  that  the  ratio  between  the  sexes  in  the  case 
of  rana  fusca  was  regularly  36.7  males  to  63.3  per  cent,  females. 

E.  Pfiilger  refers  the  divergence  between  Born's  results  and  his 
own  and  those  of  von  Grieshcim  not  to  any  error,  made  by  Born 
in  the  diagnosis  of  the  sex  of  the  tadpoles,  but  to  the  fact  that  in 
the  latter's  aquaria  the  mortality  of  the  male  tadpoles  was  probably 
greater  than  that  of  the  females.  Pfiilger  endeavoured  to  ascertain 
whether  the  concentration  of  the  semen  might  have  an  influence 
in  the  determination  of  sex.  A  quantity  of  frog-spawn  was  ferti- 
lized with  concentrated  semen,  taken  direct  from  the  seminal 
vesicles,  and  another  quantity  of  spawn  was  fertilized  with  diluted 
semen,  obtained  by  making  an  aqueous  extract  of  the  incised  tes- 
ticles. The  ratio  between  the  sexes  in  the  case  of  the  two  lots  of 
tadpoles,  which  were  kept  in  separate  aquaria,  proved,  however,  to 
be  mathematically  identical.  But  another  experiment  showed  that 
the  number  of  males  was  very  different,  according  to  the  kind  or 
race  from  which  the  animals  were  derived.  He  therefore  believes 
that  for  the  character  of  the  development  of  the  reproductive 
organs,  the  race  of  the  parent  animals  is  determinative.  There  is 
very  little  likelihood  of  being  able  to  modify  this  inherited  sexual 
ratio  by  means  of  outward  influences  affecting  the  ova  and  the  ripe 
semen  prior  to  fertilization,  and  just  as  little  by  means  of  a  number 
of  abnormal  influences  (change  of  climate,  of  water,  of  nutriment, 
etc.)  acting  on  the  fertilized  ova. 

D  using, —  who  in  his  work  on  "  The  Regulation  of  the  Sexual 
Ratio  "  (Jena,  1884)  most  ingeniously  advocates  the  thesis  that  all 
animals  have  the  power,  when  there  is  a  lack  of  individuals  of  one 
sex,  of  procreating  an  excess  of  individuals  of  this  deficient  sex, 
or,  to  put  it  in  another  way,  that  an  excess  of  one  sex  determines  the 
procreation  of  an  excess  of  the  other  sex, —  instituted  experimental 
investigations  regarding  the  determination  of  sex  in  the  following 
manner  (in  accordance  with  a  suggestion  made  by  Pfiilger}  :  About 
ninety  guinea-pigs  were  distributed  in  two  pens  in  such  a  way  that 
in  one  pen  there  was  a  great  deficiency  of  males  and  a  great  excess 
of  females,  whilst  in  the  other  there  was  a  deficiency  of  females 
and  an  excess  of  males.  Thus  the  sexual  ratios  in  the  two  stalls 
were  opposed.  In  accordance  with  Diising's  theory,  therefore, 
more  males  should  have  been  born  in  the  first  pen  and  more  females 
in  the  second  pen.  Every  week  each  pen  was  examined  once  or 
twice,  the  sex  of  the  new-born  young  was  ascertained,  and  they 


458  THE  SEXUAL  LIFE  OF  WOMAN. 

were  distinguished  by  small  incisions  in  the  margin  of  the  ear.  A 
week  later,  when  the  young  animals  had  developed  a  little  further, 
they  were  re-examined  to  make  sure  that  no  mistake  had  been  made. 

At  first,  in  the  pen  containing  the  original  excess  of  females, 
there  occurred  £  quite  remarkable  excess  of  male  births.  This, 
however,  was  merely  the  result  of  chance,  for  soon  the  relationships 
of  the  sexes  among  the  new  born  was  reversed,  and  thenceforward 
many  more  females  were  born  than  males.  But  if  all  the  births 
occurring  in  this  experiment  are  taken  into  consideration  the  num- 
ber is  still  far  too  small  to  allow  trustworthy  conclusions  to  be 
drawn. 

D using  emphasizes  the  fact  that  such  an  experiment  as  this,  in 
order  to  furnish  results  worth  consideration,  must  be  continued 
until  the  sexual  ratio  has  become  constant,  so  that  it  is  no  longer 
subject  to  alteration  by  chance  variations.  If  we  assume  that 
D  using' s  theory  is  false,  the  results  obtained  would  be  the  follow- 
ing: In  both  the  pens,  in  that  in  which  there  was  originally  an 
excess  of  females  and  in  that  in  which  there  was  originally  an  ex- 
cess of  males,  the  births,  if  observed  through  a  sufficient  period, 
would  present  a  definite  sexual  ratio  which  would  be  the  same  in 
both  the  pens.  But  if  the  theory  is  well  founded  the  sexual  ratio 
of  the  new  born  would  vary  in  the  two  pens :  in  the  stall  in  which 
there  had  originally  been  a  deficiency  of  males  there  would  be  an 
excess  of  births  of  males  over  females;  whereas  in  the  pen  in  which 
there  had  originally  been  a  deficiency  of  females  there  would 
on  the  contrary  be  an  excess  of  births  of  females  over  males. 
D  using  recommends  that  for  such  experiments  even  more  fruitful 
animals,  such  as  rats  and  mice,  should  be  utilized. 

Institutes  for  pisciculture  would  also  be  extremely  suitable  for 
such  experiments  in  breeding  for  the  determination  of  the  matter 
under  discussion  because,  owing  to  the  fact  that  in  these  animals 
fertilization  is  effected  outside  of  the  body  of  the  parents,  a  direct 
examination  of  the  ova  and  the  semen  used  in  the  experiments  can 
be  undertaken,  and  the  fertilization  can  be  made  to  occur  under 
conditions  subjected  to  various  alterations;  also  we  can  employ  the 
roe  and  the  sperm  of  fishes  whose  age,  life  history,  weight  and  size 
are  accurately  known. 

Much  attention  has  recently  been  paid  to  the  theory  of  Schenk, 
based,  as  he  states,  upon  numerous  experiments  regarding  the  in- 
fluences by  which  sex  is  determined.  This  observer  also  starts  from 
the  principle  that  ovulation  is  not  independent  of  the  influences  of 


THE  SEXUAL  EPOCH  OF  THE  MENACME.  459 

nutrition  and  metabolism.  He  believes  that  in  the  cases  in  which 
combustion  in  the  body  is  effected  in  such  a  manner  that  remnants 
of  unconsumed  substances,  still  capable  of  heat-production,  make 
their  appearance  in  the  urine,  the  ovum  of  the  human  female  in 
process  of  formation  is  not  so  far  advanced  in  its  development  as 
it  is  in  cases  in  which  the  urine  is  entirely  free  from  sugar,  or  at 
any  rate  is  free  from  any  demonstrable  traces  of  the  presence  of 
this  body.  In  the  former  case  we  shall  find  that  the  ovum  is  not 
only  less  mature,  but  also  that  it  is  presumably  less  well  nourished. 
In  his  view  such  an  ovum  is  less  completely  endowed  in  respect  of 
the  indwelling  qualities  and  forces  of  its  protoplasm,  and  it  appears 
for  this  reason  to  be  adapted  only  for  the  development  of  a  female 
individual.  But  when,  on  the  contrary,  in  the  maternal  individual, 
all  the  substances  formed  in  and  assimilated  by  the  organism  have 
undergone  combustion  so  completely  that  there  is  no  sugar  in  the 
urine,  not  even  in  the  minutest  discernible  traces,  the  maternal  body 
is  in  a  condition  suitable  for  the  development  of  an  ovum  adapted 
to  become  a  male  individual.  From  these  inferences,  weak  though 
the  chain  of  argument  is,  Schenk  draws  the  conclusion,  that  by 
the  regulation  of  the  nutritive  material  supplied  to  the  organism, 
and  by  the  suitable  choice  of  that  material,  we  are  to  a  consider- 
able extent  enabled  to  support  an  ovum  in  its  process  of  maturation 
in  such  a  manner  as  to  cause  it  to  develop  into  a  male  individual. 
The  nutritive  material  selected  for  this  purpose  must  be  of 
such  a  nature  that  the  elimination  in  the  urine  of  even  the  minutest 
quantities  of  sugar  may  be  prevented;  the  urine  must  appear  free 
from  sugar  even  when  the  phenyl-hydrazine  test  is  employed.  Thus 
in  every  case  in  which  we  wish  to  influence  a  woman's  nutrition  in 
such  a  way  as  to  lead  to  the  procreation  of  a  male  individual  we 
must  above  all  ascertain  whether,  in  the  woman  in  question,  the 
normal  quantity  of  sugar  is  present  in  the  urine.  If  after  the  most 
careful  examination  no  trace  of  sugar  can  be  found  in  the  urine, 
and  if  reducing  substances  are  present  in  this  excretion  in  abun- 
dance, no  change  need  be  made  in  the  diet,  and  all  we  have  to  do  is 
to  recommend  that  the  requisite  fertilization  should  be  effected  as 
soon  as  possible,  since  there  is  every  probability  that  in  this  condi- 
tion the  embryo  will  prove  to  be  of  the  male  sex.  But  when,  on  the 
other  hand  the  "  normal "  quantity  of  sugar  is  present  in  the  urine, 
or  when  even  traces  only  of  that  substance  can  be  detected,  it  is 
necessary  by  changes  in  the  diet  to  cause  the  disappearance  from 
the  urine  of  every  trace  of  sugar,  and  at  the  same  time  to 


460  THE  SEXUAL  LIFE  OF  WOMAN. 

about  the  appearance  in  that  fluid  of  an  abundance  of  reducing 
substances.  Schenk  claims  by  the  experiments  he  has  made  along 
these  lines  to  have  obtained  results  which  show  that  it  is  possible 
in  this  way  to  influence  the  determination  of  sex. 

His  method  is  to  nourish  the  mother  mainly  on  nitrogenous  mater- 
ials and  fat,  and  to  give  in  addition  only  so  much  carbohydrate  as 
is  necessary  to  prevent  the  absence  of  this  from  being  seriously  felt. 
This  diet  should  be  continued  for  a  considerable  period,  at  best  for 
two  or  three  months  before  the  fertilization  is  effected.  After  con- 
ception also,  the  same  diet  should  be  continued.  In  such  a  manner 
we  are  able  in  certain  cases  to  bring  about  the  procreation  of  male 
offspring.  On  the  other  hand,  the  desire  for  the  procreation  of 
female  offspring  remains  one  which  as  yet  we  have  no  direct  means 
of  fulfilling. 

These  vague  experiments  and  ill-grounded  theories  of  Schenk' s 
do  not,  as  a  matter  of  fact,  constitute  an  important  advance  in  the 
theory  of  the  voluntary  determination  of  the  sex  of  the  human  off- 
spring. What  in  reality  are  the  decisive  influences  in  the  deter- 
mination of  sex,  and  how  the  final  impulsion  in  one  direction  or  the 
other  is  actually  effected,  remain  altogether  obscure.  Prediction  of 
the  sex  of  the  offspring",  and  the  voluntary  procreation  of  male  or 
female  infants,  remain  problems  for  the  solution  of  which  the  most 
essential  data  are  still  lacking. 

Ernest  Ha-ckel  writes  regarding  Schenk's  theory:  "This  impor- 
tant 'discovery/  which  at  the  time  of  its  first  announcement  at- 
tracted throughout  the  world  an  attention  rarely  given  to  true 
scientific  advances,  has  now  dwindled  to  the  incomplete  demonstra- 
tion that  the  nutritive  condition  of  the  mother  exercises  a  certain 
influence  upon  the  determination  of  the  sex  of  the  child.  But  we 
knew  this  much  a  long  time  ago.  D Using  and  others,  partly  by 
physiological  experiments  and  partly  by  statistical  demonstrations, 
had  shown  that  changes  in  the  quantity  and  the  quality  of  the  nutri- 
ment supplied  to  either  parent  is  capable  of  influencing  the  pro- 
creation of  boys  or  girls.  But  if  what  Professor  Schenk  maintains 
were  really  true  peoples  living  chiefly  upon  meat  (as,  for  instance, 
in  the  pampas  of  South  America)  should  have  an  exceptionally 
large  proportion  of  male  offspring;  whereas  those  living  mainly  on  a 
proteid-free  diet  (on  meal,  sugar,  and  other  carbohydrates),  should 
have  an  exceptionally  large  proportion  of  female  offspring  (as,  for 
example,  the  rice-eating  Indian  and  Mongolian  nations).  But  this 
is  by  no  means  the  case.  And  many  other  well-known  facts  are 


THE  SEXUAL  EPOCH  OF  THE  MENACME.  461 

likewise  opposed  to  the  '  epoch-making '  theory  of  Schenk. 
Whether  the  fertilized  ovum  develops  into  a  boy  or  a  girl,  depends, 
I  am  convinced,  upon  far  more  complex,  and  to  a  large  extent  still 
entirely  unknown,  physiological  causes.  The  final  judgment  upon 
the  '  Schenk  theory '  must  be,  '  Much  Ado  About  Nothing.' " 

Our  exposition  of  the  present  standpoint  of  the  doctrine  of  the 
origination  of  sex  in  the  human  species,  has,  in  fact,  shown  that 
hitherto  by  statistical  work, -nor  by  anatomical  investigations,  nor, 
finally,  by  the  experimental  method,  have  results  been  obtained 
which  render  it  possible  to  predict  the  sex  of  the  unborn  infant. 
And  even  in  respect  of  the  study  of  those  influences  which  exercise 
a  determining  influence  upon  the  origination  of  sex,  no  positive, 
indisputable  conclusions  have  been  reached.  We  can  only  say  it 
appears  probable  that  there  exist  several  causes  of  the  determination 
of  sex  the  co-operative  action  of  which  proves  effectual.  Not  in 
the  ovum  alone,  nor  in  the  spermatozoon  alone,  but  in  the  reciprocal 
influence  they  exert  one  upon  tiie  other  in  the  act  of  conception 
is  sex  determined.  In  the  latter  connection  the  relative  and  abso- 
lute ages  of  the  progenitors  appear  to  have  a  certain  influence  in  the 
determination  of  the  sex  of  the  embryo;  of  importance  also  is  the 
greater  or  less  demand  made  upon  the  sexual  capacity  of  the  be- 
getter; of  influence  too  is  the  time  at  which  the  ovum  is  fertilized 
after  its  discharge  from  the  ovary.  It  appears  to  be  fairly  well 
established  that  when  the  husband  is  at  least  ten  years  older  than 
the  wife,  while  the  latter  is  at  the  age  at  which  a  woman's  repro- 
ductive powers  are  at  a  maximum,  more  boys  are  conceived  than 
girls  (Kisch)  ;  also  that  one  of  the  progenitors  upon  whose  sexual 
capacities  the  greater  demands  are  made,  tends  to  procreate  an  ex- 
cess of  -individuals  of  his  or  her  own  sex  (Piquet,  D  using}  ;  and, 
finally,  that  intercourse  a  considerable  time  after  the  cessation  of  the 
menstrual  flow  (in  the  second  week  of  the  intermenstrual  interval 
or  later)  is  favourable  to  the  procreation  of  a  male  infant  (Thury, 
Hcnsen}.  The  influence  of  nutritive  conditions  in  the  determina- 
tion of  sex  is  less  clearly  established. 

Statistical  evidence  has  proved  beyond  dispute  that  given  a  suffi- 
ciently large  number  of  instances  in  varying  conditions  the  sexual 
ratio  is  106,  and  this  fact  suggests  that  the  determination  of  sex 
is  dependent  upon  the  interaction  of  two  influences  operating  in 
opposite  directions  within  narrow  limits,  in  such  a  manner  that  the 
chances  of  the  birth  of  a  male  infant  preponderate  over  the  chances 
of  the  birth  of  a  female  infant  in  the  proportion  of  106  to  100.  In 


462  THE  SEXUAL  LIFE  OF  WOMAN. 

elucidation  of  this  fact  Hensen  makes  the  following  comparison: 
"  Let  us  imagine  a  balance  the  beam  of  which  has  two  arms 
of  equal  length;  from  the  two  extremities  of  this  beam  two  balls 
of  nearly  equal  weight  begin  to  roll  toward  one  another;  if  one 
ball  rolls  more  quickly  than  the  other,  if  one  is  lighter  than  the 
other,  or  if  one  starts  to  roll  before  the  other,  the  opposite  end  of 
the  beam  will  sink.  The  three  influences  are  variously  distributed ; 
one  influence  may  reinforce  another, -or  may  counteract  another; 
hut  a  decisive  sinking  of  one  end  of  the  beam  will  always  ultimately 
ensue.  A  minimal  shortening  or  lightening  of  one  arm  of  the 
balance  will  make  the  chance  that  the  other  arm  will  descend  corre- 
spondingly greater." 

STERILITY  IN  WOMEN. 

When  we  study  the  history  of  human  civilization  we  find  that 
sterility  in  women  is  regarded,  not  merely  as  a  misfortune,  but  as 
a  reproach.  Among  savage  races,  and  in  the  Orient,  where  the  posi- 
tion of  women  is  one  of  strict  subordination,  she  does  not  attain 
an  honourable  status  until  she  becomes  a  mother.  In  Persia,  a 
sterile  woman  is  always  divorced  by  her  husband.  In  India,  also, 
when  a  sterile  married  woman  has  in  vain  employed  the  various 
religious  measures  advocated  for  the  relief  of  her  barren  condition 
she  is  sent  back  to  her  parents.  Both  in  China  and  Japan,  a  barren 
woman  is  regarded  as  a  most  miserable  creature.  Among  the 
negro  races,  a  woman  who  fails  to  bear  children  is  the  object  of 
scorn  and  contempt.  Among  the  Dualla  negroes,  a  man  whose 
wife  fails  to  bear  children  demands  from  her  parents  the  return  of 
the  sum  which  he  paid  for  her  at  the  time  of  marriage.  Many  of 
the  indigenous  tribes  of  South  America  also  make  a  practice  of 
divorcing  a  sterile  wife.  Among  the  better-class  Circassians,  the 
women  do  not  attain  an  assured  position  until  they  have  borne  a 
child.  In  Angola  a  barren  woman  is  the  object  of  universal  con- 
tempt, and  she  often  feels  the  ignominy  of  her  position  so  keenly  that 
she  commits  suicide.  Alike  among  the  Jews  and  among  the  Turks, 
barrenness  in  a  wife  is  a  recognized  ground  for  divorce,  and  the 
woman  who  has  been  divorced  for  this  reason  will  hardly  ever  suc- 
ceed in  obtaining  another  husband,  for  she  is  regarded  as  one  whose 
body  is  not  properly  developed.  According  to  old  German  law, 
barrenness  in  a  wife  and  impotence  in  a  husband  were  both  grounds 
for  divorce.  The  code  of  the  Emperor  Justinian  allowed  of  divorce 
in  cases  in  which  for  the  space  of  two  years  a  husband  had  been 
unable  to  fulfil  his  marital  duties,  and  such  a  union  was  termed 


THE  SEXUAL  EPOCH  OF  THE  MENACME.  463 

innuptcB  nuptce.  Among  the  ancient  Romans,  although  they  regarded 
barrenness  as  a  mark  of  the  divine  disfavour,  according  to  the  laws 
of  Augustus  failure  to  bear  children  was  a  punishable  offence,  and 
such  a  punishment  was  incurred  by  any  married  woman  who  had 
attained  the  age  of  20  years  without  having  become  a  mother.  In 
ancient  Greece  also,  divorces  due  to  the  barrenness  of  the  wife 
were  by  no  means  uncommon.  Among  the  Slavonic  peoples  sterility 
was  so  greatly  despised  that  there  is  a  Slavonic  proverb  which 
runs :  "A  woman  is  no  woman  until  she  has  borne  a  child  "  :  and  in 
Istria  a  sterile  woman  is  known  by  the  nickname  "  Scirke,"  which  is 
equivalent  to  "hermaphrodite."  The  Jewish  view  of  the  matter  is 
expressed  in  the  Talmudic  rabbinical  saying:  "A  wife's  duties  are 
beauty,  gentleness,  and  the  bearing  of  children  " ;  and  again,  "  the 
poor,  the  leprous,  the  blind,  and  the  childless,  are  like  the  dead  n ; 
and,  finally,  "  he  who  refrains  from  marriage  with  the  deliberate 
intention  of  having  no  children,  incurs  the  guilt  of  murder."  In 
the  Koran  we  find  the  fatalistic  expression,  "  God  makes  a  woman 
barren  in  accordance  with  his  will." 

We  can  therefore  readily  understand  that  in  the  most  ancient 
medical  writings  the  question  of  sterility  in  women  is  a  matter  of 
earnest  consideration.  In  the  works  of  the  early  physicians  of 
Hindustan  we  find  several  apt  remarks  on  the  subject.  Susruta 
says :  "  Pregnancy  most  readily  results  from  intercourse  during 
menstruation.  At  this  time  the  os  uteri  is  open,  like  the  flower  of 
the  water  lily  in  the  sunshine."  In  the  Old  Testament,  in  which  the 
newly-created  human  couples  receive  the  command,  "  Be  fruitful 
and  multiply,  and  replenish  the  earth,"  we  find  frequent  references 
to  barrenness  as  a  state  equally  dishonourable  and  unfortunate,  and 
the  use  of  certain  plants  is  recommended  as  a  means  of  cure.  The 
Talmud  contains  several  essays  dealing  with  the  causes  and  treat- 
ment of  sterility. 

The  Hippocratic  collection  of  writings  contains  a  number  of 
passages  dealing  with  the  causes  of  sterility  and  with  the  means  to 
be  employed  for  its  relief.  We  shall  have  occasion  later  to  refer 
to  these  recommendations.  Celsus,  on  the  other  hand,  has  little  to 
say  on  this  subject.  In  the  works  of  Pliny,  and  also  in  those  of 
slristotle,  there  are  references  to  the  topic  of  sterility. 

Among  the  writers  of  the  first  century  of  our  era,  Soramis  dis- 
cusses exhaustively  the  capacity  for  conception  and  sterility. 
In  his  work  we  find,  among  other  passages,  the  unquestion- 
ably .accurate  remark:  "Since  the  majority  of  marriages  are  con- 


464  THE  SEXUAL  LIFE  OF  WOMAN. 

eluded,  not  from  love,  but  in  order  to  procreate  children,  it  is 
difficult  to  understand  why,  in  the  choice  of  a  wife,  less  regard  is 
paid  to  her  probable  fertility  than  to  the  worldly  wealth  of  her 
parents." 

In  the  middle  ages,  Paulus  Agineta  more  especially  treats  of  the 
diseases  of  women,  and  among  these,  of  sterility  in  women.  That 
in  Arabian  medicine  much  attention  was  paid  to  this  question,  we 
can  learn  from  the  writings  of  Maimonides. 

By  sterility  in  women  we  understand  the  pathological  state  in 
which  a  woman  who  is  sexually  mature  fails  to  conceive,  notwith- 
standing frequently  repeated,  normal  sexual  intercourse  throughout 
a  considerable  period  of  time. 

Sterility  is  termed  congenital  (or  absolute)  when,  notwithstanding 
repeated  intercourse  throughout  a  long  period  (not  less  than  three 
years),  pregnancy  has  always  failed  to  ensue;  it  is  termed  acquired 
(or  relative),  when  women  who  have  already  been  pregnant  once  or 
more  often,  cease  to  conceive,  although  they  are  still  quite  young 
enough  to  do  so,  and  have  experienced  regular  sexual  intercourse 
for  a  long  period  (not  less  than  three  years).  In  a  wider  sense  of 
the  term,  we  say  that  a  woman  is  sterile,  when,  notwithstanding 
prolonged  and  repeated  sexual  intercourse,  in  circumstances  favour- 
able to  procreation,  she  has  failed  to  give  birth  to  a  living  and  viable 
infant. 

English  authors  also  make  a  special  distinction  regarding  that 
form  of  acquired  sterility  (which  is  no  great  rarity),  in  which  a 
woman  gives  birth  to  a  single  infant  and  subsequently  remains 
sterile  (''only-child  sterility"). 

The  civilization  of  the  present  day,  with  its  shady  side,  has 
made  it  necessary  for  us  to  pay  an  increasing  attention  to 
facultative  sterility,  dependent  upon  the  use  during  intercourse  of 
means  for  the  prevention  of  conception;  and  very  recently 
the  surgical  tendency  of  modern  gynecology  has  brought  into  being 
a  new  variety  of  sterility  in  women,  viz.,  operative  sterility. 

The  period  which  must  elapse  after  marriage,  before  the  absence 
of  pregnancy  must  lead  us  to  regard  a  woman  as  sterile,  is  fixed 
at  three  years.  This  limitation  is  based  upon  the  statistical  data 
which  (see  Table  on  page  368)  I  gave  regarding  556  fruitful 
marriages. 

The  ideal  state  of  fertility,  that  in  which  conception  is  the  imme- 
diate result  of  the  first  act  of  intercourse  between  husband  and  wife, 
the  conception  being  followed  in  due  course  by  the  birth  of  a  child, 


THE  SEXUAL  EPOCH  OF  THE  MENACME.  465 

is,  like  most  other  ideals,  one  very  rarely  attained.  In  the  human 
species,  conception  as  the  immediate  result  of  the  first  act  of  sexual 
intercourse,  is  an  extremely  unusual  occurrence.  To  invoke  medical 
assistance  for  women  who  have  failed  to  conceive  during  the  first 
three  months  of  married  life,  which  my  experience  shows  to  be 
more  frequently  done  now  than  formerly,  is  devoid  of  all  justifica- 
tion ;  and  still  worse  is  it,  in  this  period  of  "  early  love  "  to  subject 
women,  as  has  often  been  done  recently  by  overenergetic  gyneco- 
logists, to  local  treatment,  even  to  the  extent  of  operative  procedures. 

We  are  not  justified  in  speaking  of  the  existence  of  actual  ster- 
ility until  three  years  of  marital  intercourse  have  failed  to  result 
in  conception ;  still,  when  the  commencement  of  the  first  pregnancy 
is  delayed  for  more  than  sixteen  months  after  marriage,  there  is 
considerable  probability  that  the  woman  is  sterile;  and  this  prob- 
ability increases  month  by  month  till  the  expiry  of  the  second  year, 
whilst  as  the  end  of  the  third  year  approaches,  it  becomes  tanta- 
mount to  certainty. 

Sterility  is  one  of  the  commonest  of  the  functional  disorders  of 
women,  and  one  of  those  which  most  often  demand  gynecological 
assistance. 

By  a  statistical  study  of  the  marriages  of  the  royal  and  princely 
families  of  Europe  and  of  the  marriages  of  the  highest  families  of 
the  aristocracy,  I  learned  that  of  626  marriages,  70  were  barren; 
thus  the  ratio  of  fruitless  to  fruitful  marriages  proved  to  be  as 
1:8.87.  But  in  other  circles  of  society,  in  so  far  as  data  relating' 
to  the  matter  were  obtainable  in  my  practice,  the  statistics  of  in- 
fertility were  by  no  means  so  unfavourable,  the  ratio  working  out 
at  about  I  barren  to  10  fruitful  unions.  I  must  point  out,  however, 
that  these  statistics,  like  all  statistics  of  fertility,  are  to  a  degree 
invalidated  by  the  fact  that  in  a  certain  number  of  the  instances 
included  among  the  barren,  an  unnoticed  abortion  may  have 
occurred. 

Simpson,  in  his  investigation  regarding  the  frequency  of  sterile 
unions,  found  a  ratio  of  1 : 8.5  (in  1252  instances).  In  the  English 
aristocracy,  where  the  marriages  are  for  the  most  part  restricted 
among  the  members  of  a  comparatively  small  number  of  families, 
the  ratio  was  1:6.11  (495  instances);  on  the  other  hand,  among 
the  population  of  Grangemouth  and  Bathgate,  consisting  chiefly 
of  persons  engaged  in  seafaring  and  agricultural  occupations,  the 
ratio  of  barren  to  fruitful  unions  was  as  1 :  10.5. 

30 


466  THE  SEXUAL  LIFE  OF  WOMAN. 

Spencer  Wells  and  Marion  Sims,  as  a  result  of  their  investiga- 
tions, give  a  ratio  of  1 :  8. 

According  to  Sceligmann,  in  Hamburg,  among  marriages  of  per- 
sons in  all  classes  of  society,  11.5$  are  barren.  Procho-wnick  found 
among  2500  women,  all  of  whom  had  been  married  for  eighteen 
months  or  more,  and  none  of  whom  were  more  than  40  years  of 
age,  that  9$  had  failed  to  conceive. 

According  to  Frank  and  Burdock,  who  do  not  publish  the  figures 
upon  which  their  estimate  is  based,  only  i  marriage  in  50  proves 
barren.  Lever,  who  also  gives  merely  his  percentage  result,  states 
that  5^  of  married  women  are  completely  infertile.  Hcdin,  dealing 
with  a  Swedish  community  of  800  persons,  states  that  the  per- 
centage of  sterile  unions  is  barely  10. 

According  to  Goehlert's  statistical  investigations,  in  the  dynasty 
of  the  Capets,  among  450  marriages,  19.7$  were  sterile:  in  the 
Wittelsbach  dynasty  (Bavaria),  among  177  marriages,  23.7^  were 
sterile ;  and  among  the  ruling  families  of  Germany  (more  than  600 
marriages),  20. 5$  were  sterile.  In  this  investigation,  however,  no 
attention  is  paid  to  the  age  of  husband  or  wife ;  marriages  and 
remarriages  are  classed  together  without  discrimination;  and  those 
marriages  only  in  which  a  living  child  was  born  are  counted  as  fruit- 
ful, so  that  the  unions  counted  as  sterile  must  contain  many  in  which 
abortion  or  stillbirth  occurred.  In  three  Esthonian  communities 
in  Livonia,  Oehren  found  that  among  2799  marriages,  8.4$  were 
barren,  but  in  this  instance  also  stillbirths  were  ignored. 

Ansell  reports  that  of  1919  marriages  of  women  belonging  to  the 
upper  classes,  their  mean  age  being  25  years,  152  proved  barren,  a 
proportion  of  1 : 12,  or  about  8#. 

Matthews  Duncan  communicates  the  following  data.  In  the  year 
1855,  in  the  cities  of  Edinburgh  and  Glasgow,  4447  marriages  were 
contracted,  and  of  these  725  proved  barren,  a  proportion  of  1 :6.i ; 
75  of  these  may  however  be  excluded  from  consideration,  inasmuch 
as  the  wives  were  already  at  the  age  of  45  or  upwards.  Among 
the  remaining  4372  marriages,  662  proved  barren,  a  proportion  of 
i  \6.6.  In  other  words,  15^  of  all  marriages  of  women  between  the 
ages  of  15  and  44  proved  sterile. 

From  France  we  obtain  figures  showing  a  much  higher  propor- 
tion of  sterile  unions.  According  to  Rochard,  in  France  in  the  year 
1888,  of  ten  millions  families,  two  million  had  no  child  at  all,  and 
two  million  had  each  an  only  child,  so  that  two  fifths  of  the  families 
of  France  were  taking  no  practical  part  in  the  maintenance  of  the 


THE  SEXUAL  EPOCH  OF  THE  MENACME. 


467 


population.  According  to  Chevin,  the  proportion  in  France  of 
barren  to  fruitful  marriages  is  as  1 :  5.  20$  are  entirely  barren,  while 
24$  exhibit  only-child-sterility. 

From  Massachusetts,  Morton  reports  that  according  to  the  last 
census  returns,  one  fifth  of  all  married  women  are  childless. 

In  England,  numerous  trustworthy  statistics  can  be  obtained  re- 
garding the  frequency  of  sterile  marriages.  The  average  propor- 
tion of  barren  to  fruitful  unions  was  : 


Among  the  patients  in  St.  Bartholomew's  Hospital I 

Among  the  inhabitants  of  Grangemouth    I 

Among  the  inhabitants  of  Bathgate   I 

Among  the  British  peerage i 

Among  the  upper  classes I 

Among  the  inhabitants  of  Edinburgh  and  Glasgow I 


Matthews  Duncan  compiled  the  following  table  relating  to  504 
absolutely  sterile  women  met  with  in  his  practice : 


AGE  AT 

MARRIAGE. 

Less 

than  3. 

4  to  8. 

9  to  13. 

14  to    18. 

19  to    23. 

24  to   28. 

29. 

Totals. 

15  to  19.  ... 

12 
7O 

19 
66 

15 
37 

4 
24 

7 
13 

2 

I 

60 

47 

51 

20 

8 

8 

134 

26 

8 

i 

59 

6 

4 

6 

Totals  

167 

172 

84 

40 

29 

I  I 

I 

5°4 

Ansell  bases  upon  the  observations  made  by  him  in  the  case  of 
152  sterile  women  the  conclusion  that  there  is  no  longer  any  chance 
of  the  occurrence  of  pregnancy  if  a  woman  is : 

More  than  48  years  old,  and  has  had  no  child  for 2  years 

More  than  47  years  old,  and  has  had  no  child  for 3  years 

More  than  46  years  old,  and  has  had  no  child  for 4  years 

More  than  45  years  old,  and  has  had  no  child  for 6  years 

More  than  44  years  old,  and  has  had  no  child  for 8  years 

Less   than    44  years  old,  and  has  had  no  child  for 10  years 

If  we  take  into  account  also  cases  of  acquired  sterility,  the  pro- 
portion of  barren  to  fruitful  marriages  becomes  even  more  un- 
favourable, and  the  proportion  increases  enormously  if,  with  Gri'tne- 
ivaldt,  we  number  among  the  barren  women  those  who  fail  to  con- 
tinue childbearing  up  to  the  normal  climacteric  period.  Grilne- 
waldt,  dealing  with  about  1500  women  suffering  from  affections  of 
the  reproductive  organs,  excluded  all  those  who  were  either  virgins 


468  THE  SEXUAL  LIFE  OF  WOMAN. 

or  widows,  and  also  all  those  who  at  the  time  of  the  observed  barren- 
ness were  over  35  years  of  age ;  this  left  more  than  900  women  suf- 
fering from  affections  of  the  reproductive  organs,  all  of  whom  were 
sexually  mature,  and  were  living  in  marital  intercourse;  of  these, 
nearly  500  were  barren,  300  being  instances  of  acquired  sterility, 
and  190  instances  of  congenital  sterility.  Thus,  according  to  this 
observer,  disease  of  the  reproductive  organs  in  women  led  in  more 
than  50^  of  the  cases  to  disturbance  of  the  reproductive  capacity; 
about  one  in  every  three  women,  previously  competent  to  bear 
children,  became  barren  when  affected  with  disease  of  the  repro- 
ductive organs ;  and  among  every  five  gynecological  patients  of  the 
condition  already  specified  as  regards  age  and  sexual  intercourse, 
one  proves  congenitally  sterile. 

It  must  not,  however,  be  forgotten,  that  sooner  or  later  after 
marriage  artificial  sterility  tends  to  come  into  being,  its  early  or  late 
appearance  depending  upon  the  degree  of  civilization  and  upon  the 
national  and  economical  conditions  of  the  people  and  the  individuals 
concerned.  This  fact  must  not  be  left  out  of  the  account. 

The  manner  in  which,  in  the  human  species,  fertilization  is 
effected,  is  still  far  from  clear  in  all  its  details;  hence  it  is  easy  to 
understand,  that  the  etiology  of  sterility  remains  in  many  respects 
obscure.  It  is  impossible  in  every  case  to  find  a  definite  cause. 
Whereas,  on  the  one  hand,  notwithstanding  the  existence  of  appar- 
ently insuperable  obstacles,  impregnation  may  nevertheless  be 
effected ;  so,  on  the  other  hand,  sterility  may  exist  in  cases  in 
which  all  the  circumstances  appear  favourable  to  the  occurrence  of 
conception.  Hence  a  classification  of  the  different  varieties  of  ster- 
ility from  the  etiological  standpoint,  is  a  very  difficult  task,  and  the 
conclusions  thus  obtained  are  often  vitiated. 

Although  it  cannot  be  denied  that  mechanical  causes  are  compe- 
tent to  lead  to  sterility  in  women,  Sims,  in  his  advocacy  of  the 
mechanical  doctrine  of  sterility,  widely  overshoots  the  mark.  His 
authority,  however,  has  led  to  a  general  acceptance  of  this  doctrine, 
which  is  by  no  means  justified  by  facts.  The  theory  of  mechanical 
obstruction,  according  to  which  sterility  in  women  depends  upon 
mechanical  obstacles  to  the  passage  of  the  spermatozoa  towards 
the  ovaries,  is  from  time  to  time  strikingly  illustrated  by  cases 
coming  under  our  notice  —  cases  the  nature  of  which  can  hardly  be 
overlooked ;  but  it  is  quite  wrong  to  suppose  that  this  causation  ac- 
counts for  the  majority  of  instances  of  sterility  in  women,  and 


THE  SEXUAL  EPOCH  OF  THE  MENACME.  469 

strict  limitations  should  be  placed  upon  the  employment  of  -surgical 
measures  based  upon  this  mechanical  theory  of  sterility. 

The  mechanical  view  has  been  counterposed  by  Von  Grilnc- 
waldt  with  a  doctrine  in  which  especial  stress  is  laid  upon  obstacles 
to  utero-gestation,  sterility  being  regarded  as  a  functional  disorder 
brought  about  by  affections  of  the  female  reproductive  organs  ren- 
dering the  uterus  unfit  for  the  incubation  of  the  ovum.  It  cannot 
be  denied  that  the  elucidation  of  this  casual  influence  was  a  valuable 
contribution  to  the  theory  of  sterility,  and  it  is  unquestionable  that 
many  morbid  conditions  of  the  uterus  exist  capable  of  giving  rise 
to  sterility  in  this  manner ;  but  we  must  avoid  the  error  of  regarding 
this  doctrine  as  a  full  explanation  of  the  cause  of  sterility. 

If,  however,  both  of  these  theories  of  sterility  are  insufficient, 
we  cannot  regard  a  third  theory,  that  of  Matthews  Duncan,  as  filling 
the  gaps  in  our  knowledge.  It  would  be  most  unfortunate  if  this 
author  were  right  in  maintaining  that  all  our  knowledge  of  the 
causes  of  sterility  is  to  be  summed  up  in  the  phrase  "  deficient  re- 
productive energy;"  we  cannot  agree  with  Duncan  in  his  belief  that 
"  Sterility  is  an  imperfection  devoid  of  all  perceptible,'  measurable 
characteristics ;"  nor  can  we  follow  him  when  he  maintains  that 
local  causes,  whether  they  are  such  as  hinder  conception,  or  such  as 
hinder  utero-gestation,  have  a  very  limited  sphere  of  activity.  Mat- 
thezi's  Duncan  adopts  an  incomprehensible  standpoint  when  he  re- 
gards sterility  as  dependent  upon  a  law  of  nature,  as  a  condition 
which  may  affect  distinct  classes  or  an  entire  population. 

According  to  the  latest  doctrine  of  sterility,  only  in  quite  ex- 
ceptional instances  is  the  woman  regarded  as  responsible  for  the 
occurrence  of  sterility;  contrariwise,  the  male  genital  organs  are 
commonly  blamed  for  the  affection,  which  is  in  the  overwhelming 
majority  of  cases  supposed  to  be  due  to  azoospermia,  usually  de- 
pendent upon  gonorrhceal  infection;  compare  with  this,  affections 
of  the  female  reproductive  organs  are  said  to  play  a  quite  subordi- 
nate role  in  the  etiology  of  sterility.  But  for  my  part,  though  I  rec- 
ognize the  important  share  that  gonorrhoea  in  the  male  plays  in  the 
causation  of  sterility,  I  am  of  opinion  that  the  extreme  view  just 
mentioned  is  by  no  means  justified  by  the  facts. 

Sterility,  a  functional  disturbance  of  an  extremely  complicated 
nature,  can,  in  my  opinion,  be  most  usefully  elucidated  from  the 
etiological  standpoint  by  starting  with  the  assumption  that  three 
conditions  are  absolutely  essential  to  procreation : 


470  THE  SEXUAL  LIFE  OF  WOMAN. 

1.  that   ovulation   proceeds   in   a   perfectly   normal   manner,  the 
maturation  of  the  discharged  ova  being  complete  ; 

2.  that  normal  spermatozoa  have  access  to  these  normal  ova  (con- 
jugation of  male  and  female  pronuclei)  ; 

3.  that  the  uterus  is  properly  adapted  for  the  gestation  of  the 
fertilized  ovum. 

My  classification  of  the  varieties  of  sterility  corresponds  to  these 
conditions  of  procreation : 

1.  sterility  due  to  incapacity  for  ovulation; 

2.  sterility  due  to  some  hindrance  to  the  conjugation  of  ovum 
and  spermatozoon  (tinder  this  head  come  also  those  cases  in  which 
the  male  is  at  fault  —  azoospermia,  and  the  like)  ; 

3.  sterility  due  to  incapacity  for  gestation. 

It  must  also  be  admitted  that  there  are  additional  causes  of  ster- 
ility, causes  which  lie  beyond  our  control.  Moreover,  as  I  have 
already  mentioned,  in  most  cases  of  sterility,  we  have  to  do,  not  with 
a  single  cause,  but  with  the  resultant  of  two  or  more  cooperating 
causes. 

Incapacity  for  Ovulation. 

Incapacity  for  ovulation,  the  first  and  most  decisive  cause  of 
sterility  in  women,  may  be  absolute  and  irremediable,  or  relative  and 
transient.  We  have  to  do  with  the  former  in  cases  in  which  the 
ovaries  are  entirely  wanting,  .or  when  they  are  affected  with  organic 
disease  to  such  a  degree  that  they  have  become  incapable  of  fulfilling 
their  function  of  ovulation ;  incapacity  for  ovulation  is,  on  the  other 
hand,  relative  and  transient  in  certain  pathological  states  of  the 
ovary  and  neighbouring  organs,  when  there  is  incomplete  develop- 
ment or  partial  atrophy  of  the  ovaries,  when  there  are  new-growths 
of  the  ovaries,  in  cases  of  oophoritis  and  perioophoritis,  in  conse- 
quence of  disturbances  of  innervation,  diseases  of  the  central  and 
peripheral  nervous  system,  violent  emotional  disturbance,  consti- 
tutional disorders,  such  as  syphilis,  chlorosis,  anaemia,  universal 
lipomatosis,  scrofula,  alcoholism,  and  morphinism,  also  in  conse- 
quence of  changes  in  the  supply  of  nutriment  and  in  the  general 
mode  of  living,  or  of  senile  changes,  and  finally  in  consequence  of 
hereditary  influences. 

The  diagnosis  of  the  etiological  influence  of  suppressed  or  in- 
complete ovulation  in  the  production  of  sterility  in  women  is  at 
times  beset  with  great  and  even  insuperable  difficulties.  The  state 
of  the  menstrual  function,  suppression  of  the  flow,  or  the  regularity 
or  irregularity  of  its  occurrence,  serve  indeed  to  inform  us  as  to 


THE  SEXUAL  EPOCH  OF  THE  MENACME.  471 

the  general  activity  or  inactivity  of  the  function  of  ovulation;  but 
the  variations  in  this  function  give  no  certain  information  as  to 
whether  a  woman  is  fertile  or  infertile.  Knowing  as  we  do  that 
generally  speaking  an  intimate  connexion  subsists  between  menstru- 
ation and  ovulation,  we  are  indeed  able  to  assert  that  regular 
menstruation  and  fertility  in  women  run  a  parallel  course,  and 
further,  that  the  greater  the  irregularity  of  the  menstrual  function, 
the  greater  the  tendency  to  sterility.  Recently,  great  advances  have 
been  made  in  the  technique  of  manual  exploration  of  the  ovaries, 
and  by  means  of  vaginal  and  rectal  bimanual  examination,  we  are 
now  able  to  obtain  accurate  information  regarding  abnormalities 
in  the  size,  shape,  and  position  of  these  organs,  and  regarding  any 
other  intra-pelvic  disorders.  In  this  way  we  have  been  enabled  to 
recognize  a  number  of  pathological  states  of  the  ovaries  which 
affect  the  functions  of  these  organs.  In  some  cases  also  there  are 
general  symptoms  which  furnish  us  with  the  means  of  drawing 
conclusions,  more  or  less  trustworthy,  regarding  the  state  of  the 
ovarian  functions;  for  instance,  the  general  development  of  a 
woman's  body,  the  condition  of  the  external  genitals,  the  vulva, 
the  mons  veneris,  the  pubic  hair,  the  clitoris,  and  the  mammae. 
Again,  we  can  derive  information  from  various  troubles  of  which 
women  complain ;  such  as  sacrache ;  a  sense  of  weight  and  pressure 
in  the  pelvis ;  feelings  of  tension  and  shooting  pains  in  the  breasts ; 
flushings  of  the  face ;  haemorrhage  from  the  nose,  mouth,  or  rectum, 
recurring  at  regular  intervals  and  vicarious  in  nature.  In  many  in- 
stances, however,  it  will  only  be  by  obtaining  data  regarding  the 
age,  mode  of  life,  and  family  history,  of  the  person  affected,  that  it 
will  be  possible  to  draw  conclusions  as  to  the  cause  of  the  sterility. 

The  female  reproductive  glands,  the  ovaries,  may,  owing  to  de- 
velopmental disturbances  during  foetal  life,  either  be  entirely  want- 
ing, or  they  may  merely  be  deprived  of  certain  structural  constitu- 
ents, especially  their  epithelial  elements.  In  the  former  case,  we 
have  congenital  complete  unilateral  or  bilateral  absence  of  the 
ovary,  a  condition  most  commonly  associated  with  the  absence  or 
with  a  rudimentary  condition  of  other  portions  of  the  reproductive 
apparatus ;  in  the  latter  case,  we  have  the  condition  somewhat  in- 
appropriately named  congenital  atrophy  of  the  ovary. 

Complete  absence  of  both  ovaries  necessarily  leads  to  absolute 
sterility.  Both  congenital  absence  and  congenital  atrophy  of  the 
ovaries,  will  usually  be  found  in  association  with  other  anomalies 
of  the  sexual  organs.  Absence  of  one  ovary,  on  the  other  hand, 
by  no  means  entails  sterility;  on  the  contrary,  when  a  single  well- 
formed  ovary  exists,  ovulation  usually  proceeds  in  a  perfectly 


472  THE  SEXUAL  LIFE  OF  WOMAN. 

normal  manner.  When  such  women  marry,  pregnancy  usually  fol- 
lows in  the  normal  proportion  of  cases ;  and,  in  complete  opposition 
to  one  of  the  theories  of  the  determination  of  sex  to  which  allusion 
has  been  made,  such  women  bear  children  of  both  sexes. 

Morgagni  described  a  case  of  congenital  absence  of  both  ovaries 
in  a  woman  66  years  of  age,  in  whom  the  external  genital  organs, 
the  vagina,  and  the  uterus,  were  imperfectly  developed,  but  the 
Fallopian  tubes  were  of  normal  size.  Careful  examination  of  the 
upper  borders  of  the  broad  ligaments  of  the  uterus  disclosed  no 
trace  of  ovary  on  either  side. 

Ouain,  in  a  virgin  33  years  of  age,  found  the  vagina  rudimen- 
tary, with  its  mucous  membrane  but  slightly  corrugated;  at  the 
upper  end  of  this  passage  was  a  semilunar  fold  which  probably 
represented  the  uterus.  The  ovaries  were  absent;  a  small  gland- 
like  body  embedded  in  the  left  wall  of  the  vagina  was  regarded  by 
him  as  a  rudimentary  ovary.  The  configuration  of  the  body  was 
feminine,  feminine  also  the  disposition;  moreover,  fchere  was  a 
monthly  recurrent  epistaxis. 

The  atrophy  of  the  ovaries  which  normally  takes  place  at  the 
climateric  period,  to  be  more  minutely  described  in  the  section  on 
the  menopause,  has  constitutional  effects  similiar  to  those  dependent 
upon  absence  or  congenital  atrophy  of  the  ovaries. 

A  rudimentary  condition  of  both  ovaries,  or  bilateral  atrophy  of 
these  organs,  with  or  without  associated  atrophy  of  the  entire  re- 
productive system,  commonly  entails  sterility.  In  such  cases,  in  ad- 
dition to  amenorrhoea,  we  usually  find  that  the  breasts  are  but 
slightly  developed,  the  pubic  hair  is  scanty,  the  labia  majora  and 
labia  minora  are  small,  whilst  sexual  appetite  is  deficient,  and  during 
coitus  the  woman  is  entirely  passive.  On  the  other  hand,  we  must 
riot  make  the  mistake  of  inferring  from  the  fact  that  the  sexual 
appetite  is  keen  and  coitus  pleasurable,  that  therefore  the  capacity 
for  ovulation  is  normal.  Even  after  operative  removal  of  both 
ovaries,  some  women  have  assured  me,  not  only  that  the  sexual 
impulse  was  as  strong  as  formerly,  but  even  that  they  continued  to 
experience  the  sexual  orgasm  in  its  full  intensity.  This  is  analo- 
gous to  the  well  known  fact  that  men  who  have  undergone  cas- 
tration after  arriving  at  sexual  maturity  may  remain  capable  of 
performing  coitus.  It  is  a  matter  of  history  that  in  the  lupinars  of 
ancient  Rome,  castrated  men  were  kept  to  enable  women  to  enjoy 
the  pleasures  of  sexual  intercourse  without  fear  of  consequences ; 
and  it  is  said  that  such  men  are  to  be  found  in  Italian  brothels  to 
this  day.  In  the  case  of  the  lower  mammals,  it  appears  to  be  the 
rule  that  when  the  reproductive  glands  are  removed  in  early  youth, 
every  trace  of  sexual  desire  disappears. 

Incomplete  development  of  the  ovaries,  with  consequent  defective 
ovulation,  may  result  from  marriage  in  girls  who  are  still 


THE 'SEXUAL  EPOCH  OF  THE  MENACME.  473 

immature  —  a  fact  already  known  to  Aristotle,  who  wrote,  "prema- 
ture marriage  leads  to  a  scanty  progeny  —  that  this  is  the  case  in 
man  as  well  as  the  lower  animals  is  witnessed  by  the  weakly  in- 
habitants of  regions  in  which  child-marriage  is  common." 

It  is  shown  by  statistical  data  that  the  age  at  which  puberty 
occurs,  the  age,  that  is,  at  which  the  menstrual  flow  begins,  has  a 
relation  to  sterility ;  and  the  same  is  true  as  regards  the  age  at 
marriage.  In  the  former  connexion,  women  in  whom  puberty  is  com- 
paratively early,  are  less  often  sterile  than  those  in  whom  puberty 
is  comparatively  late.  Emmet,  in  an  investigation  embracing 
2330  cases,  showed  that  in  our  climate  the  average  age  at  which 
the  first  menstruation  occurred  was  14.23  years,  and  that  in  the 
case  of  women  who  subsequently  proved  fertile,  the  first  flow  took 
place  on  an  average  26  days  earlier  than  in  the  case  of  women  who 
subsequently  proved  barren.  We  also  learn  from  Emmet's  tables 
that  the  mean  duration  of  menstruation  and  the  mean  quantity  of 
the  flow  are  larger  in  fertile  than  in  barren  women. 

As  regards  the  influence  of  the  age  at  marriage  upon  fertility, 
in  women  who  marry  between  the  ages  of  20  and  24  years,  sterility 
is  most  infrequent ;  it  is  commoner  in  women  who  marry  between 
the  ages  of  14  and  20;  after  the  age  of  25,  the  proportion  of  sterile 
women  increases  with  each  year  to  which  marriage  is  postponed. 

Premature  atrophy  of  the  ovaries,  with  consequent  incapacity  for 
ovulation,  may  occur  in  a  great  variety  of  conditions;  it  has  been 
observed  in  scrofula,  diabetes,  rickets,  phthisis,  and  malarial  ca- 
chexia;  it  also  occurs  in  certain  chronic  intoxications,  as  from  the 
long-continued  use  of  opium  or  morphine,  and  from  the  abuse  of 
alcoiiolic  beverages.  According  to  the  observation  'of  Burkart, 
Levinstein,  and  Erlcnmcyer,  morphinism  is  a  condition  which  may 
be  relied  upon  to  bring  about  amenorrhoea  and  temporary  sterility 
from  cessation  of  ovulation.  It  has  been  asserted  but  by  no  means 
proved,  that  the  long-continued  administration  of  quinine  hinders 
ovulation.  As  a  result  of  various  acute  and  chronic  disorders,  a 
simple  atrophy  of  the  ovarian  follicles  can  be  detected,  dependent 
upon  simple  fatty  degeneration ;  this  has  been  seen  by  Grohc  in 
children  as  a  result  of  general  atrophy,  and  also  following  caseous 
and  suppurative  diseases  of  the  respiratory  organs ;  by  Slavjansky  in 
children  after  chronic  pneumonia  and  chronic  dysentery,  and  in 
adults  as  a  sequel  of  typhoid,  and  in  one  instance  as  a  sequel  of 
puerperal  septicaemia. 

Hyperplasia  of  the  ovarian  stroma,  in  slighter  degrees  of  the 
affection,  leads  to  menstrual  disturbances,  partly  of  nervous  and 
partly  of  inflammatory  nature,  and  in  more  severe  degrees  leads  to 
sterility  dependent  upon  the  hindrances  which  the  thickened  tunica 
albuginea  offers  to  the  bursting  of  the  mature  follicles.  Klebs  be- 


474  THE  SEXUAL  LIFE  OF  WOMAN. 

lieves  that  this  anomaly  is  always  due  to  a  disposition  acquired  very 
early  in  life,  and  perhaps  at  the  time  when  the  ovaries  are  first 
developed. 

Follicular  cysts  of  the  ovary,  which  are  formed  mostly  at  the 
time  of  puberty,  and  originate  under  the  influence  of  menstrual 
congestion,  from  graafian  follicles  near  to  ripeness,  are  competent 
to  cause  sterility,  owing  to  the  pressure  they  exercise  upon  the 
superficially  placed  rudimentary  follicles,  leading  to  the  atrophy  of 
these  latter.  Other  new-growths  of  the  ovaries  have  similar  effects, 
such  as  adenomata,  carcinomata,  dermoid  cysts,  cystomata,  sar- 
comata, and  fibromata.  In  many  cases  of  these  disorders,  however, 
the  ovarian  follicles  may  for  long  periods  remain  unaffected;  and 
in  these  instances,  ovulation,  menstruation,  and  even  conception, 
may  proceed  undisturbed.  Even  in  cases  in  which  a  neoplasm  at- 
tains a  great  size,  if  it  affects  one  ovary  only,  ovulation  may  occur 
normally  in  the  other,  and  conception  may  ensue ;  and  even  in  the 
diseased  ovary,  if  small  portions  of  its  tissue  remain  unaffected, 
ovules  may  be  discharged  from  these  portions.  The  minutest  por- 
tion of  healthy  ovarian  tissue,  though  all  the  remainder  has  been 
destroyed  by  disease,  may  suffice  to  bring  about  conception. 

Ovarian  tumours  appear  with  considerable  frequency  to  be  com- 
plicated with  sterility ;  but  in  such  cases  the  question  always  remains 
open,  whether  in  the  majority  of  instances  the  sterility  is  to  be  re- 
garded as  the  cause  or  as  the  consequence  of  the  ovarian  disease. 
Boinet's  figures  dealing  with  this  problem  are  the  most  striking  of 
all.  He  states  that  of  500  women  with  ovarian  tumours,  390  were 
childless.  But  these  results  are  challenged  by  other  observers. 
Veil's  estimates,  based  upon  a  compilation  of  the  figures  of  Lcc, 
Scansoni,  and  West,  is  that  34$  of  women  with  ovarian  tumour  are 
sterile.  On  the  other  hand,  Ncgroni's  collection  of  400  cases  of 
ovarian  tumour,  including  both  married  and  unmarried,  contained 
43  only  who  had  never  been  pregnant.  Other  lists  show:  13 
sterile  women  among  45  suffering  from  ovarian  tumour  (i'on 
Scansoni)  ;  I  sterile  among  21  (Nussbaum)  ;  8  sterile  among  63 
(Olshanscn).  IVinckel,  among  150  sterile  married  women,  found 
32  suffering  from  ovarian  tumour,  which  in  two  of  these  cases 
only  was  bilateral.  Atlce,  in  15  cases  of  ovarian  tumour,  observed 
premature  cessation  of  menstruation  at  the  ages  of  30,  39,  40  and 
42,  respectively. 

Although  in  many  cases  sterility  develops  coincidently  with  the 
growth  of  an  ovarian  cystoma,  yet  in  many  other  women  such 
tumours  have  no  influence  in  diminishing  fertility.  Martin  in  a 
case  in  which  sterility  existed  in  connexion  with  a  unilateral  ovarian 
cystoma,  the  other  ovary  being  healthy,  observed  pregnancy  as  a 
sequel  of  the  removal  of  the  diseased  ovary.  In  one  of  these  cases, 


THE  SEXUAL  EPOCH  OF  THE  MENACME.  475 

after  removal  of  the  ovarian  cystoma,  Martin  punctured  in  the 
other  ovary  a  dropsical  follicle  which  had  attained  nearly  the  size 
of  a  walnut.  Pregnancy  in  this  case  also  followed  the  resumption 
of  marital  intercourse.  Milller  reports  that  in  his  clinique  within 
recent  years  pregnancy  complicated  with  ovarian  tumour  has  been 
observed  in  7  instances;  in  one  of  these  cases  the  pregnancy  oc- 
curred notwithstanding  the  fact  that  the  new-growth  was  so  large 
as  almost  to  fill  the  abdominal  cavity.  Hoist  reports  the  case  of  a 
multipara  43  years  of  age  who  died  in  the  i8th  to  the  2Oth  week 
of  pregnancy;  at  the  post  mortem  examination  the  left  ovary  was 
found  to  be  transformed  into  three  cysts  each  the  size  of  an  apple, 
whilst  in  place  of  the  right  ovary  was  a  medullary  carcinoma  the 
size  of  a  man's  head ;  on  neither  side  could  a  trace  of  normal  ovarian 
tissue  be  detected.  Spiegelbcrg,  in  a  woman  who  died  shortly  after 
giving  birth  to  her  second  child,  found  that  both  ovaries  were  trans- 
formed into  myxo-sarcomatous  tumours ;  in  a  woman  aged  42,  who 
died  four  weeks  after  her  eleventh  confinement,  both  ovaries  were 
found  to  be  transformed  into  nodular  carcinomatous  tumours  each 
larger  than  a  child's  head;  in  none  of  these  ovaries  was  any  normal 
stroma  to  be  found.  Ruge  reports  the  case  of  a  woman  36  years 
of  age,  who  miscarried  in  the  sixth  month  of  pregnancy;  she  had 
myxo-sarcoma  of  both  ovaries,  one  weighing  5620  grammes  the 
other  480  grammes. 

All  these  cases  indicate  that,  notwithstanding  the  existence  of 
extensive  degeneration  of  both  ovaries,  some  minute  remaining 
fragment  of  healthy  ovarian  stroma  is  competent  to  produce  normal 
mature  ova  —  a  fact  which  has  often  been  proved  also  by  micro- 
scopical examination.  That  under  the  influence  of  pregnancy,  ex- 
isting ovarian  tumours  often  take  on  extremely  rapid  growth,  is 
also  indicated  by  some  of  the  above  cases. 

Castration  (oophorectomy,  spaying,  Battcy's  operation),  the 
removal  of  both  ovaries,  naturally  results  in  sterility.  If  in 
the  literature  of  the  subject  cases  are  to  be  found  in  which, 
'after  this  operation,  not  menstruation  merely,  but  even  pregnancy 
has  occurred,  this  is  to  be  explained  either  by  the  fact  that  in  the 
stump  there  was  left  a  fragment  of  the  ovary,  still  containing  tissue 
capable  of  producing  mature  ova;  or  else  by  the  existence  of  a 
supernumerary  ovary.  5 chats  reports  the  case  of  a  woman  in 
whom  pregnancy  occurred  after  double  oophorectomy.  In  the 
month  of  February,  1880,  this  operation  was  performed  on  a  girl 
twenty  years  of  age;  she  married  in  April,  1884;  and  in  May, 
1885,  she  was  delivered  of  a  mature  female  infant.  The  history  of 
the  case  and  the  details  of  the  operat:on  showed  clearly  that  the 
lett  ovary  had  been  completely  removed,  with  the  outermost  third 
of  the  left  Fallopian  tube ;  the  right  ovary  was  cut  away  in  such  a 


476  THE  SEXUAL  LIFE  OF  WOMAN. 

manner  that  a  strip  of  tissue  of  at  most  two  millimetres  (one 
twelfth  of  an  inch)  in  width  was  left  in  the  body,  whilst  the  right 
Fallopian  tube  was  left  intact.  This  case  teaches  us  that  the  smallest 
remnant  of  the  ovary  is  competent  to  render  normal  pregnancy 
possible ;  and  further,  that  a  small  size  of  the  ovary  no  more  con- 
stitutes a  hindrance  to  the  proper  reception  of  the  ovum  in  the 
Fallopian  tube,  than  does  an  abnormally  large  size  of  the  ovary, 
or  an  unusual  shape  of  this  organ. 

Miklucho-Mackay  relates  that  among  the  indigens  of  Australia 
the  removal  of  the  ovaries  is  often  practised,  in  order  to  create  a 
special  kind  of  hetairae  incapable  of  becoming  mothers.  McGillivray 
saw  at  Cape  York  a  native  gin  whose  ovaries  had  been  removed 
because  she  was  a  congenital  deaf-mute,  with  the  object  of  prevent- 
ing her  giving  birth  to  deaf-mute  infants.  In  the  beginning  of  the 
last  century  there  existed  in  Sayn-Wittgenstein  a  small  religious 
sect  whose  custom  it  was  always  to  conclude  their  religious  services 
by  indiscriminate  carnal  union  among  the  members  of  the  com- 
munity ;  when  women  and  girls  were  first  admitted  as  members  of 
this  sect,  an  attempt  was  made  to  render  them  unfitted  for  conception 
"  by  means  of  a  painful  and  dangerous  compression  of  the  ovaries." 
(Plots.) 

A  transient,  relative  hindrance  to  ovulation  may  be  brought  about 
by  various  pathological  states  of  the  ovaries.  Acute  oophoritis 
usually  suspends  the  ovarian  functions ;  chronic  oophoritis  has 
sometimes  a  similar  effect,  not  only  because  the  profound  changes 
that  take  place  in  the  ovary  hinder  the  formation  of  the  ovules,  but 
also  because,  as  we  shall  later  explain  more  fully,  the  expulsion  of 
the  ova  and  their  reception  by  the  Fallopian  tubes  are  hindered.  In 
severe  oophoritis  and  perioophoritis,  more  especially  in  parenchy- 
matous  inflammation,  sterility  may  be  brought  about  by  an  absorp- 
tion of  the  finely  granular  contents  of  the  follicles,  which  collapse, 
with  adhesion  of  their  walls;  when  all  or  most  of  the  follicles  are 
thus  affected,  the  ovaries  become  small  and  hard. 

In  perioophoritis,  the  exudation  leads  to  the  formation  of  cord- 
shaped  or  ribbon-shaped  adhesions  between  the  ovaries  and  the 
broad  ligaments,  the  uterus,  and  the  peritoneal  folds  of  the  neigh- 
bourhood. The  ovary  in  such  cases  may  also  be  displaced,  or  may 
undergo  atrophy  from  pressure. 

In  the  case  of  200  sterile  women,  I  found  in  46  instances  chronic 
oophoritis  and  perioophoritis.  Olslwuscn  reports  that  of  12  married 
women  suffering  from  chronic  oophoritis,  five  were  barren,  whilst 
of  the  remaining  7,  three  only  had  given  birth  to  more  than  one 
child.  Matthews  Duncan,  on  the  other  hand,  saw  pregnancy  in  .a 
case  of  bilateral  ovarian  inflammation,  in  which  the  organs  were 
considerably  enlarged. 


THE  SEXUAL  EPOCH  OF  THE  MENACME.  477 

Further,  local  or  general  peritonitis  may  lead  to  perenchymatous 
inflammation  of  the  ovaries,  and  this,  spreading  from  the  periphery 
towards  the  centre  of  the  organ,  attacks  the  follicles  irrespective  of 
their  ripeness.  Again,  during  the  puerperium,  the  interstitial  form 
of  oophoritis  is  by  no  means  rare,  and  this  may  at  times  lead  to 
permanent  sterility  in  either  of  two  ways :  it  may  be  in  consequence 
of  the  onset  of  a  secondary  parenchymatous  inflammation,  which 
destroys  all  the  follicles ;  it  may  be  because  a  thick  and  tough  layer 
of  sclerosed  tissue  forms  around  the  periphery  of  the  ovary,  which 
mechanically  prevents  the  maturation  and  rupture  of  the  follicles. 
According  to  Slavjansky,  puerperal  disease  is  the  principal  cause  of 
this  form  of  oophoritis.  Olshauscn  indicates  as  the  most  frequent 
cause  of  primary  perioophoritis,  an  inflammation  propagated  from 
the  Fallopian  tubes,  leading  to  the  formation  of  masses  of  exudation, 
which  envelop  the  ovary,  and  by  the  pressure  they  cause,  and  by 
interfering  with  the  blood-supply,  lead  to  atrophy  of  the  gland. 

Sometimes  the  chronic  inflammatory  induration  by  means  of  which 
the  stroma  of  the  ovary  is  rendered  denser  and  firmer,  is  due  to 
changes  in  the  vessels,  and  depends  upon  valvular  defects  of  the 
heart — upon  venous  congestion.  In  this  way,  heart  disease  may 
hinder  ovulation  and  bring  about  sterility.  Both  syphilis  and  gonor- 
rhoea may  give  rise  to  chronic  inflammatory  changes  in  the  ovary, 
usually  leading  to  premature  contraction  of  the  tissues  and  to  the 
formation  of  numerous  adhesions.  According  to  Olshauscn,  amenor- 
rhoea  is  not  a  common  feature  of  ovarian  disease,  except  in  cases 
of  defective  development  of  these  organs,  of  cirrhosis  of  the  ovaries, 
and  of  bilateral  new-growths.  Disease  affecting  only  a  single  ovary, 
even  tumour  of  considerable  size,  rarely  causes  amenorrhoea  until 
profound  constitutional  disturbance  has  ensued.  An  exception  to 
this  rule  is  found  in  the  case  of  carcinomatous  tumours  of  the  ovary ; 
these,  indeed,  are  commonly  bilateral ;  but  even  when  confined  to 
a  single  ovary,  amenorrhoea  is  a  comparatively  early  symptom. 
According  to  the  same  author,  sterility  is  a  common  consequence 
of  chronic  oophoritis  and  its  sequelae,  and  is  usual  also  in  cases  of 
bilateral  new-growths ;  on  the  other  hand,  tumours  affecting  a 
single  ovary  often  fail  to  prevent  conception  even  though  they  have 
attained  a  great  size. 

Syphilis  in  women  must  be  regarded  as  a  frequent  cause  of 
sterility,  by  interference  with  ovulation,  but  is  in  this  regard  by  no 
means  an  absolute  bar  to  the  occurrence  of  pregnancy.  According 
to  Parent  and  Duchatclct,  under  whose  observation  during  the  space 
of  12  years  there  came  annually  an  average  number  of  2625  syphilitic 
prostitutes,  the  average  annual  of  births  in  these  cases  was  63  only. 
According  to  Marc  d'E spine,  2000  prostitutes  gave  birth  on  an 
average  to  two  or  three  children  in  all  during  a  year.  (That  there 


478  THE  SEXUAL  LIFE  OF 

are  other  causes  besides  syphilis  for  the  remarkable  infertility  of 
women  of  the  town,  will  be  explained  later).  According  to  Bednar, 
Mayr,  and  others,  constitutional  syphilis  in  women  invariably  leads  to 
sterility;  others,  as  for  instance  Zeissl,  believe  that  women  suffering 
from  inveterate  syphilis  are  commonly,  but  not  invariably,  sterile; 
whilst  according  to  Rosen,  conception  only  takes  place  in  syphilitic 
women  in  whom  the  disease  has  passed  into  the  tertiary  form.  Ex- 
perience shows,  however,  that  neither  early  nor  late  forms  of 
syphilis  necessarily  lead  to  sterility  in  women.  It  must  also  be 
pointed  out,  that  syphilis  in  the  male  may  be  the  cause  of  sterility, 
and  must  be  the  cause  thereof  when  the  disease  is  localised  in  the 
testicles,  and  the  consequent  degeneration  of  the  glandular  substance 
leads  to  the  occurrence  of  azoospermia,  more  particularly  when 
syphilitic  or  gummatous  orchitis  is  bilateral.  According'  to  Lcwin, 
we  fail  to  find  spermatozoa  in  50$  of  men,  otherwise  powerful, 
suffering  from  syphilitic  dyscrasia.  Hanc,  on  the  other  hand,  failed 
to  find  azoospermia  in  any  one  of  ten  men  suffering  from  lues.  In 
animals  also  syphilis  is  said  to  cause  sterility. 

The  manner  in  which  certain  anomalies  of  the  blood  (anaemia 
and  chlorosis),  general  disturbances  of  the  nervous  system,  febrile 
states,  and  such  constitutional  disorders  as  scrofula,  have  a  tempo- 
rary or  permanent  influence  in  checking  ovulation,  is  far  from  being 
understood  ;  but  tile  fact  that  ovulation  is  checked  by  such  conditions, 
has  been  established  beyond  question  by  numerous  observations. 
It  is  well  known  that  severe  fevers,  more  especially  typhoid,  suspend 
the  ovarian  function ;  that  in  various  chronic  disorders  of  an  en- 
feebling nature,  and  notably  in  chlorosis,  all  signs  of  menstrual 
activity  disappear;  and  that  in  certain  nutritive  disturbances,  as  in 
extreme  obesity,  amenorrhoea  also  occurs ;  finally,  numerous  cases 
are  on  record  in  which  some  sudden  affection  of  the  nervous  system 
has  instantaneously  inhibited  ovarian  activity. 

In  anaemia  and  chlorosis,  it  is  probable  that  the  degree  of  men- 
strual congestion  is  insufficient  to  ensure  the  bursting  of  the  graafian 
follicle.  The  sterility  often  observed  as  a  sequel  of  typhoid,  malaria, 
the  acute  exanthemata,  cholera,  and  septicaemia,  is  probably  due  in 
most  cases  to  the  occurrence  of  parenchymatous  oophoritis,  with 
consequent  destruction  of  the  ovarian  follicles.  The  researches  of 
Slavjansky  have  shown  that  in  acute  disorders  inflammatory  changes 
often  occur  in  the  graafian  follicles.  When  infectious  disorders 
ran  an  acute  course,  this  observer  usually  found  that  the  parenchy- 
matous inflammation  of  the  ovary  had  occurred  near  the  periphery, 
in  the  cortical  layer,  the  destruction  being  limited  almost  exclusively 
to  the  primitive  follicles ;  when  the  course  of  the  primary  disorder 
was  more  chronic,  the  mature  or  nearly  mature  graafian  follicles 
were  the  ones  destroyed.  When  inflammation  of  a  follicle  has  led 


THE  SEXUAL  EPOCH  OF  THE  MENACME.  479 

to  its  destruction,  it  is  replaced  by  a  linear  scar.  Lcbcdinsky  found 
similar  changes  in  the  ovary  after  scarlatina — destruction  of  a  lesser 
or  greater  number  of  follicles,  with  formation  of  scars.  Thus, 
parenchymatous  oophoritis  as  a  sequel  of  acute  diseases,  may,  if 
severe,  lead  to  destruction  of  all  the  rudimentary  follicles,  with  con- 
sequent sterility.  In  the  post  mortem  examination  of  such  cases, 
the  condition  of  the  ovaries  is  similar  to  that  which  is  elsewhere  in 
this  work  described  as  characteristic  of  these  organs  after  the 
menopause :  the  ovary  is  diminished  in  size,  its  surface  is  furrowed, 
the  tissue  is  indurated  in  consequence  of  overgrowth  of  fibroid 
tissue ;  often  not  a  single  follicle  is  to  be  detected  on  section  of  the 
organ. 

Immoderate  obesity  is  a  disorder  of  nutrition  favoring  the  occur- 
rence of  sterility. 

In  very  obese  women  of  an  age  which  normally  is  the  reproductive 
prime,  amenorrhoea  or  scanty  menstruation  is  a  very  common  ac- 
companiment. In  215  such  cases  which  came  under  my  own  obser- 
vation, amenorrhoea  was  present  in  49,  and  menstruation  was 
scanty  in  116;  thus  in  nearly  three  fourths  of  these  obese  women 
menstruation  was  either  deficient  or  entirely  wanting.  Very  re- 
markable also  is  the  high  percentage  of  sterile  women  among  the 
obese.  In  the  215  cases  already  mentioned  (all  married  women). 
48  were  sterile — a  percentage  of  21.  Whilst  the  ordinary  ratio  of 
barren  to  fruitful  marriages  is  1 :  10  or  1:9,  in  the  cases  in  which 
the  wives,  or  both  wives  and  husbands,  are  extremely  obese,  the 
ratio  is  according  to  my  own  observations,  1:5 — or,  if  we  include 
cases  of  only-child-sterility,  I  '.4. 

\Ye  cannot  wonder  at  this  great  frequency  of  sterility  in  obese 
women  when  we  remember  that,  apart  from  the  menstrual  deficien- 
cies which  so  commonly  accompany  this  disorder  of  nutrition,  obesity 
is  apt  to  entail  many  other  disorders  of  the  reproductive  organs,  as 
for  instance  a  morbid  state  of  the  uterine  and  vaginal  secretions, 
chronic  metritis,  and  displacements  of  the  uterus ;  still,  it  cannot  be 
denied,  that  in  many  instances  we  are  unable  in  such  obese  women 
to  detect  any  disorder  of  the  reproductive  organs  competent  to 
account  for  the  sterility,  and  we  must  therefore  assume  that  the 
excessive  development  of  fat  has  some  direct  influence  in  preventing 
ovulation,  or  at  least  that  it  in  some  way  exercises  an  unfavourable 
influence  upon  the  reproductive  process. 

That  excessive  obesity  hinders  fertility,  is  shown  by  experience 
both  as  regards  the  vegetable  and  the  animal  kingdom.  All  animal- 
breeders  are  familiar  with  the  fact  that  undue  production  of  fat 
limits  fertility.  Thus,  equally  in  the  case  of  turkeys  and  in  the 
case  of  the  common  fowl,  if  the  hens  are  overfed  and  become  fat, 
they  cease  to  lay. 


480  THE  SEXUAL  LIFE  OF  WOMAN. 

Hippocrates  already  indicated  obesity  as  a  cause  of  sterility. 
Writing  of  the  wives  of  the  Scythians,  he  pointed  out  as  a  proof 
that  their  excessive  obesity  was  the  cause  of  the  sterility  from  which 
they  commonly  suffered,  the  fact  that  their  female  slaves,  who  were 
thin,  were  readily  impregnated  by  intercourse  with  the  Scythian 
males.  The  oft  repeated  dwindling  and  disappearance  of  ruling 
families  in  India  and  in  Egypt,  has  doubtless  in  part  depended  upon 
the  extreme  obesity  of  the  female  consorts  of  such  rulers. 

In  many  instances,  indeed,  a  great  accumulation  of  fat  on  the 
front  of  the  abdomen  and  in  the  vulva,  suffices  to  cause  a  simply 
mechanical  hindrance  to  the  proper  performance  of  a  fertilizing 
coitus.  It  is  possible  also  that  the  phlegmatic  temperament  of  very 
fat  women  is  a  contributory  cause  to  their  sterility — if  indeed  it  is  in 
general  true  that  frigidity  during  sexual  intercourse  is  unfavourable 
to  conception,  as  is  expressed  by  the  old  proverb,  quo  salacior  mulicr, 
co  foecundior.  It  is  unquestionable  that  in  very  obese  women 
sexual  sensibility  is  commonly  greatly  deficient,  and  that  their  hus- 
bands often  complain  of  their  coldness  and  lack  of  passion.  In 
several  cases  that  have  come  under  my  observation,  dyspareunia 
occurred  in  obese  and  sterile  women. 

The  dependence  of  sterility  upon  obesity  is  often  proved  in  the 
most  striking  manner  ex  juvantibus.  A  "  cure  "  for  the  reduction 
of  fat  often  results  favourably  in  respect  also  of  rendering  the 
woman  who  undergoes  it  readily  impregnable — a  result  by  no  means 
ardently  desired. 

It  must  also  be  pointed  out  that  very  obese  women  form  a  consid- 
erable section  of  those  suffering  from  only-child  sterility,  and  this 
largely  in  consequence  of  their  strong  predisposition  towards  abor- 
tion. As  the  impregnated  uterus  enlarges,  the  space  for  its  accom- 
modation is  insufficient,  owing  to  the  great  development  of  the  pan- 
niculus  adiposus,  and  thus  obesity,  like  intraabdominal  tumour, 
predisposes  to  abortion.  The  excessive  accumulation  of  fat  within 
the  abdomen,  by  exercising  pressure  upon  the  inferior  vena  cava  or 
on  its  principal  tributaries,  hinders  the  venous  return,  and  gives  rise 
to  a  chronic  stasis  in  the  uterine  bloodvessels,  those  alike  of  the 
muscle  and  of  the  mucous  membrane. 

Notwithstanding  the  fact  that  sterility  is  so  common  in  very 
obese  women,  the  fact  remains  that  some  such  women  are  remark- 
ably fertile,  and  have  very  large  families  indeed. 

Towers-Smith,  Duke,  and  Rodriguez,  who  have  recently  all  been 
engaged  in  examining  the  relations  between  obesity  and  sterility, 
agree  in  asserting  that  sterility  due  to  obesity  may  be  cured  by 
dietetic  treatment  for  the  relief  of  the  primary  disorder  of  meta- 
bolism. 

Though  menstruation  is  usually  deficient  or  absent  in  obese  sterile 


THE  SEXUAL  EPOCH  OF  THE  MENACME.  481 

women,  and  though  it  is  commonly  supposed  that  amenorrhoea 
implies  sterility,  it  is  necessary  to  point  out  that  whilst  failure  of 
menstruation  is  a  frequent  and  important  sign  of  suppression  of 
ovulation,  it  by  no  means  invariably  has  this  significance.  It  is  an 
established  fact,  and  one  borne  out  by  my  personal  experience,  that 
women  who  have  never  menstruated  have  nevertheless  become 
pregnant;  others,  again,  have  become  pregnant  although  they  have 
ceased  to  menstruate  for  several  years,  and  this  has  even  occurred 
in  women  at  a  comparatively  advanced  age.  Hence,  from  the 
fact  that  amenorrhoea  exists,  we  cannot  with  certainty  infer  that  a 
woman  is  sterile.  Moreover,  we  must  remember  that  physiologically 
amenorrhoeic  women  often  enough  conceive — during  lactation.  Al- 
though we  hold  the  opinion  that  there  is  an  intimate  connexion 
between  ovulation  and  menstruation,  yet  it  is  always  possible  in 
cases  in  which  menstruation  fails  to  occur,  that  ovulation  has  taken 
place,  but  that  the  stimulus  which  that  process  has  exercised  upon 
the  reproductive  organs  has  been  insufficient  to  give  rise  to  the 
customary  flow  of  blood. 

The  following  remarkable  case  came  under  my  own  observation: 
Mrs.  B.,  26  years  of  age,  had  lived  in  sterile  wedlock  for  six  years, 
has  never  menstruated,  nor  had  she  ever  had  any  sanguineous  dis- 
charge from  the  genitals.  The  body  was  delicately  formed,  the  breasts 
were  fairly  well  developed,  the  external  genital  organs  showed  no 
abnormality.  For  some  weeks  before  consulting  me,  this  woman, 
hitherto  childless,  and  living  in  regular  sexual  intercourse  with  her 
husband,  had  noticed  a  remarkable  enlargement  of  the  abdomen. 
Another  medical  man  whom  she  had  consulted  had  diagnosed  ovarian 
tumor  and  had  urged  operation.  A  more  careful  examination  of 
the  pelvis  showed,  however,  that  the  woman  was  in  the  sixth  month 
of  pregnancy,  a  diagnosis  which  was  duly  confirmed  by  the  delivery 
of  a  full-time  child.  In  another  of  my  cases,  a  woman  married  at 
the  age  of  45  years,  having  ceased  to  menstruate  two  years  pre- 
viously. She  became  pregnant  and  gave  birth  to  a  child  in  quite 
normal  fashion.  The  following  instructive  case  also  came  under 
my  own  observation :  The  wife  of  one  of  my  colleagues,  living  in 
sterile  wedlock  for  17  years,  extremely  obese,  had  since  puberty, 
menstruated  but  scantily  and  with  great  irregularity.  The  menstrual 
interval  was  several  months,  and  when  the  discharge  did  appear, 
it  was  pale  in  colour  and  small  in  quantity ;  it  lasted  moreover  but 
a  day  or  two.  Last  winter,  the  flow  as  usual  failed  to  appear  for 
several  months,  and  since  the  woman  had  at  the  same  time  become 
fatter  than  ever,  Turkish  baths  and  energetic  muscular  movements 
were  prescribed.  The  result  of  this  treatment  was  a  striking  one — 
abortion.  After  17  years  of  marital  intercourse  she  had  for  the  first 
time  become  pregnant. 
31 


482  THE  SEXUAL  LIFE  OF  WOMAN. 

In  the  case  of  sterile  women  who  are  amenorrhoeic,  even  when 
the  amenorrhoea  has  never  been  interrupted  by  a  menstrual  dis- 
charge, or  when  it  appears  entirely  dependent  upon  obesity,  it  is 
nevertheless  necessary  to  be  extremely  cautious  in  making  a  diag- 
nosis, and  above  all  in  employing  an  intra-uterine  sound.  In  such 
cases  I  have  known  the  most  eminent  gynecologists  unwittingly 
bring  about  abortion. 

Cleveland,  Godcfroy,  Haschek,  Ritschie,  Sommerus,  Stark,  Taylor, 
and  Young,  have  all  reported  cases  in  which  pregnancy  occurred 
in  women  suffering  from  amenorrhoea;  but  all  such  cases  must  be 
regarded  as  quite  exceptional.  Szukits  examined  8000  sexually 
mature  women,  and  found  among  them  fourteen  only  who  had 
never  menstruated.  Of  these,  four  were  multiparae. 

Saint  Moulin  reports  the  case  of  a  woman  24  years  of  age  who 
had  never  menstruated,  but  who  none  the  less  became  pregnant  and 
gave  birth  to  a  fine  girl.  One  of  the  most  striking  cases  of  this 
nature  is  the  one  reported  by  Rodzcivitsch,  regarding  a  woman 
who  first  began  to  menstruate  at  the  age  of  36  years.  This  woman 
had  however  been  married  when  fifteen  years  of  age,  and  in  the 
subsequent  twenty-one  years  she  gave  birth  to  15  children,  remain- 
ing the  whole  time  amenorrhoeic. 

Pucch  reports  the  case  of  a  woman  who  ceased  to  menstruate  at 
the  age  of  40  years,  and  remained  amenorrhoeic  for  the  subsequent 
six  years.  Then  menstruation  recurred  for  a  year,  and  finally  ceased 
definitively  in  consequence  of  the  occurrence  of  pregnancy,  which 
terminated  in  the  normal  birth  of  a  healthy  boy.  Loezvy,  in  a  woman 
31  years  of  age,  who  had  previously  been  amenorrhoeic  all  her 
life,  saw  menstruation  appear  for  the  first  time  shortly  after  the 
birth  of  her  sixth  child.  Ahlfcld  had  under  observation  the  case  of 
a  woman  who  was  the  mother  of  eight  children,  and  had  never 
menstruated. 

Kricgcr  reports  the  case  observed  by  Mayer,  of  the  wife  of  an 
artizan,  who  between  the  ages  of  17  and  28  years  had  given  birth  to 
five  children,  and  had  had  one  abortion.  After  the  age  of  22,  she 
had  no  trace  of  menstrual  discharge,  imt  notwithstanding  this,  she 
subsequently  gave  birth  to  three  children.  Kricgcr  himself  saw  a 
woman  who  had  had  her  last  child  at  the  age  of  33,  and  in  whom 
now,  at  the  age  of  48,  menstruation  had  just  ceased  entirely.  Two 
years  later,  irregular  menstrual  discharges  recommenced  ;  when  these 
ceased,  it  appeared  that  the  woman  was  once  more  pregnant,  and 
she  was  normally  delivered  of  a  full-time  girl. 

Rcnandin  relates  the  case  of  a  lady  60  years  of  age  who  gave 
birth  to  a  child,  menstruation  having  ceased  12  years  earlier.  Dcsh- 
haycs  saw  the  delivery  of  a  woman  50  years  of  age,  two  years 
subsequent  to  the  occurrence  of  a  normal  menopause. 


THE  SEXUAL  EPOCH  OF  THE  MENACME.  483 

quotes  the  case  of  a  woman  who  became  pregnant  at  the  age  of  65 
years.  In  this  case  menstruation  had  recurred,  having  ceased  many 
years  before  in  a  normal  menopause.  This  woman  aborted  at  three 
months,  and  the  foetus  was  well-formed. 

In  such  cases  of  late  conception,  which  occur  after  the  normal 
cessation  of  menstrual  activity,  we  cannot  be  certain  whether  we 
have  to  do  with  a  simple  persistence  of  ovarian  activity,  associated 
with  temporary  or  permanent  cessation  of  menstruation ;  or  whether 
both  functions,  ovulation  and  menstruation,  had  ceased,  and  were 
aroused  to  renewed  activity  by  some  determinate  cause.  It  is  pos- 
sible that  in  coitus  we  have  such  a  stimulus,  capable  of  reawakening 
the  slumbering  ovarian  functions.  That  this  may  be  the  case,  we 
are  led  to  suppose  by  the  fact  that  pregnancy  at  an  unusually  ad- 
vanced age  most  frequently  occurs  as  a  result  of  marriage  late  in 
life.  In  Scandinavian  countries,  where  the  difficulties  of  providing 
for  a  family  are  so  great  that  a  very  large  number  of  marriages 
are  inevitably  postponed  till  comparatively  late  in  life,  the  number 
of  pregnancies  occurring  in  elderly  women  is  correspondingly  large. 
However,  pregnancy  late  in  life  occurs  also  in  women  who  have 
married  early,  and  the  most  probable  assumption  to  account  for 
such  cases  is  that  ovulation  has  occurred  in  the  absence  of  men- 
struation. 

Although  by  these  cases  the  proposition  is  established  that  amenor- 
rhoea  is  by  no  means  equivalent  to  incapacity  for  ovulation,  still, 
the  former  must  indubitably  be  regarded  as  in  general  a  most  im- 
portant indication  of  disturbed  ovulation.  When  a  woman  attains 
the  age  of  20  years  without  having  ever  menstruated,  or  even  having 
experienced  menstrual  molimina,  we  may  in  the  great  majority  of 
such  cases  infer  with  justice  tihat  there  is  complete  or  partial  failure  of 
development  of  the  ovaries  and  the  reproductive  apparatus  generally. 
In  some  of  these  cases,  examination  discloses  the  fact  that  the  uterus 
is  in  an  infantile  condition.  When  we  are  able  to  bring  about  the 
regular  establishment  of  menstruation,  we  may  hope  also  to  remove 
the  sterility  dependent  upon  the  defective  ovarian  functional  capacity. 
General  tonic  treatment  for  the  relief  of  chlorotic  amenorrhoea  quite 
as  often,  in  the  case  of  previously  barren  married  women,  results  in 
the  occurrence  of  pregnancy,  as  happens  in  cases  of  amenorrhoea 
and  sterility  due  to  obesity,  when  this  latter  condition  has  been 
relieved  and  menstruation  has  been  reestablished  by  suitable  dietetic 
treatment.  Much  less  often  is  it  possible  to  relieve  the  sterility  of 
scrofulous  (tuberculous)  persons,  for  in  the  majority  of  such  cases, 
in  consequence  of  the  scrofulous  (tuberculous)  constitutional  dis- 
orders, pathological  changes  have  occurred  in  the  ovaries  already 
in  early  youth,  and  these  it  is  difficult  or  more  often  impossible  to 
remove. 


484  THE  SEXUAL  LIFE  OF  WOMAN. 

Scrofula  (tuberculosis)  is,  according  to  my  own  experience,  the 
constitutional  disorder  which  of  all  most  frequently  and  most  seri- 
ously affects  ovulation ;  and  it  appears  that  the  ovaries  are  subject 
to  changes  produced  by  this  disease  similar  to  those  which  occur 
in  other  glandular  organs.  In  cases  in  which  no  cause  of  the 
existing  sterility  is  ascertainable,  the  presence  of  scars  due  to  scrofu- 
lous (tuberculous)  changes  in  the  lymphatic  glands  may  serve  as  ah 
indicator  to  show  that  the  capacity  for  ovulation  has  been  annihilated 
or  seriously  diminished  in  early  life  by  scrofulous  (tuberculosis) 
disease. 

Among  the  causes  of  sterility,  these  three  conditions :  anaemia, 
chlorosis,  and  scrofula  (tuberculosis),  play  a  leading  part;  indeed, 
their  importance  in  this  connexion  has  hitherto  been  underestimated, 
more  especially  in  regard  to  the  comparative  frequency  with  which 
they  cause  sterility.  A  large  part  of  the  favourable  influence  in 
the  relief  of  sterility  in  women  which  is  exercised  by  the  "  cures  " 
at  various  watering  places,  depends  upon  the  amelioration  which 
is  thus  effected  in  the  aforesaid  constitutional  disorders. 

It  has  been  assumed  that  diabetes,  which  renders  men  impotent,  is 
competent  also  to  cause  sterility  in  women.  Hof meter  reports  a 
case  which  appears  decisive  on  this  point.  In  a  woman  20  years 
of  age,  who  had  menstruated  regularly  since  she  was  14  until  a 
year  previously,  when  the  flow  had  ceased,  he  found  the  uterus 
extremely  small,  barely  5  cm.  (2  in.)  in  length,  extremely  atrophied, 
the  ovaries  also  aitrophied  and  very  small ;  the  urine  contained  large 
quantities  of  sugar.  Here  was  doubtless  a  case  of  atrophy  of  the 
reproductive  organs  secondary  to  diabetes. 

In  England,  where  the  excessive  use  of  alcohol  is  observed  very 
frequently  in  women  as  well  as  in  men,  sterility  has  frequently 
been  regarded  as  a  result  of  chronic  alcoholism.  Matthews  Duncan 
reports  cases  which  lead  to  the  belief  that  alcohol  has  a  specifically 
deleterious  effect  upon  fertility.  Apart  from  the  general  or  con- 
stitutional disturbances  dependent  upon  the  abuse  of  alcohol,  this 
agent  has  in  many  cases  a  well-recognized  pathogenic  influence 
upon  the  female  reproductive  organs,  the -morbid  condition  which 
is  most  frequently  and  most  readily  assignable  to  this  cause  being 
chronic  oophoritis.  The  obesity  which  so  frequently  results  from 
alcoholic  excess  is  a  contributory  cause  of  sterility. 

Certain  drugs,  more  especially  quinine  and  morphine,  are  reputed 
to  cause  sterility.  Davics,  reviving  an  old  opinion,  considers  that  of 
all  drugs  tannin  is  the  most  effective  in  leading  to  sterility,  and  he 
considers  tea-drinking  as  responsible  for  this  effect. 

The  influence  of  certain  cerebral  affections  and  psychical  disorders 
in  checking  ovulation  has  been  established.  Thus,  dc  Moutyel  has 
recently  shown  that  in  families  subject  to  hereditary  mental  dis- 


THE  SEXUAL  EPOCH  OF  THE  MENACME.  485 

orders,  there  is  an  unusually  large  proportion  (1:7)  of  barren 
marriages. 

In  addition,  there  are  many  influences  which  are  known  to  prevent 
or  to  diminish  ovulation  in  the  case  of  the  lower  animals,  and  which 
may  therefore  be  assumed  with  considerable  probability  to  have  a 
similar  effect  in  women.  More  especially  we  are  here  concerned 
with  external  influences  affecting  unfavourably  nutrition  and  inner- 
vation,  and  therewith  also  ovulation ;  also  near  kinship  between  the 
parties  to  the  act  of  intercourse ;  and  finally  hereditary  predisposi- 
tion. In  animals,  captivity,  exposure  to  cold,  over-exertion,  insuf- 
ficient or  unsuitable  food,  and  inbreeding,  have  been  proved  to  result 
in  infertility. 

Doubleday  asserted  that  "  a  too  abundant  supply  of  nutriment 
hinders  reproduction,  whereas  on  the  other  hand  insufficient  or 
improper  food  favours  reproductive  activity  and  increases  the  num- 
ber of  the  offspring:"  Spencer,  however,  rightly  points  out  that  the 
infertility  noticed  in  these  circumstances*  is  not  the  direct  result  of 
prosperity,  but  depends  upon  the  pathological  obesity  which  is  thus 
engendered  by  overfeeding. 

No  less  interesting  are  the  observations  that  have  been  made 
regarding  sterility  in  animals  in  confinement.  In  such  animals  there 
are  wide  differences.  Some  refuse  to  cohabit,  or  have  lost  sexual 
desire;  others,  again,  show  excessive  sexual  desire  and  cohabit  too 
often,  without  any  result;  or  even  if  fertilization  occurs,  abortion 
often  ensues.  In  yet  other  cases,  though  conception  follows  inter- 
course, and  the  animals  go  on  to  full  term  before  delivery,  the  young 
are  still-born,  or  are  weakly  and  misshapen.  Caged  birds  often 
lay  no  eggs  at  all  or  very  few ;  or  if  they  do  lay,  they  neglect  their 
eggs ;  or  if  incubated,  the  eggs  fail  to  hatch  out.  In  France,  ex- 
periments regarding  this  matter  were  made  with  domestic  fowls.  If 
the  hens  were  given  great  freedom,  20  per  cent  only  of  the  eggs 
remained  unhatched ;  with  less  freedom,  40  per  cent  of  the  eggs 
were  failures ;  whilst  if  the  fowls  were  kept  in  a  coop,  60  per  cent 
of  the  eggs  were  unhatched. 

"  Convincing  proofs,"  writes  Darwin,  "  have  been  obtained  to  the 
effect  that  wild  animals  which  have  recently  lost  their  freedom  have 
their  fertility  diminished  to  a  most  remarkable  extent.  This  infer- 
tility is  not  dependent  upon  any  degeneration  of  the  reproductive 
organs.  There  are  many  animals  of  the  most  diverse  species,  which, 
whilst  they  copulate  freely  in  confinement,  fail  in  these  circumstances 
to  conceive ;  others  again,  even  if  they  conceive  and  have  living 
young,  give  birth  to  these  in  numbers  which  are  unquestionably 
much  smaller  than  would  be  the  case  were  the  parents  in  the  free 
state." 

Interesting  observations   have  been   made  by   pigeon   breeders. 


486  THE  SEXUAL  LIFE  OF  WOMAN. 

They  state  that  when  pigeons  brought  up  in  the  same  nest  pair,  the 
number  of  their  offspring  is  usually  very  small. 

The  influence  upon  fertility  of  unfavourable  conditions  of  tem- 
perature, either  excessive  heat  or  excessive  cold,  is  very  great.  In  the 
case  of  pigeons,  for  instance,  if  the  pigeon  cot  is  adjacent  to  the 
heated  wall  of  a  dwelling  house,  the  pigeons  sometimes  begin  to  lay 
as  early  as  January,  and  may  have  young  as  often  as  eight  times 
in  a  single  year.  When  the  dovecot  is  cold,  on  the  other  hand,  the 
number  of  broods  is  smaller.  In  general,  the  procreative  capacity 
is  greater  in  summer  than  in  winter. 

As  regards  inbreeding,  many  facts  are  on  record  showing  the 
influence  of  this  practice  in  leading  to  the  birth  of  malformed 
offspring  and  to  sterility.  Daru'in  writes,  "  if  in  a  pure  race, 
characterized  by  a  certain  tendency  to  sterility,  we  allowed  only 
brothers  and  sisters  to  pair,  in  a  few  generations  the  stock  would 
become  extinct."  If  animals  closely  related  by  blood  pair,  the  num- 
ber of  their  offspring  is  always  less  than  the  average. 

In  the  case  of  the  human  species,  however,  the  influence  of  the 
marriage  of  near  kin  in  diminishing  fertility  cannot  be  regarded  as 
definitely  proved. 

Occasionally  the  incapacity  for  ovulation  and  the  sterility  de- 
pendent thereupon  are  hereditary — paradoxical  as  this  may  appear. 
It  is  necessary  to  assume,  that  just  as  the  sperm  is  at  times  unsuited 
for  effective  fertilization,  so  also  the  ova  may  be  in  a  less  or  greater 
degree  insusceptible  of  fertilization.  In  the  present  state  of  our 
knowledge,  indeed,  we  are  not  in  a  position  to  be  precise  as  to  the 
exact  nature  of  such  incapacity.  It  is  possible  that  the  enveloping 
membrane  of  the  ovum  varies  in  its  resistance  to  penetration,  as 
Schenk  claims  to  have  proved  in  respect  of  certain  of  the  lower 
mammals.  In  his  experiments  on  artificial  fertilization  outside  the 
body  of  the  mother,  he  ascertained  that  the  cells  derived  from  the 
discus  proligerus,  surrounding  the  ovum  in  immediate  contact  with 
the  zona  pellucida,  are  in  some  instances  easily  separable  one  from 
another,  so  that  the  spermatozoa  can  readily  obtain  access  to  the 
zona  pellucida ;  whereas  in  other  instances,  in  which  the  ovum  is 
of  the  same  size  and  apparently  in  the  same  stage  of  maturation 
as  before,  these  cells  remain  closely  attached  each  to  the  other,  and 
thus  prevent  the  passage  of  the  spermatozoa.  This  condition  of  the 
ovum,  so  unfavourable  to  fertilization,  may  be  hereditary  in  certain 
families,  and  its  transmission  may  render  certain  members  of  the 
stock  infertile.  Such  instances  as  the  following  from  my  own 
practice  are  by  no  means  rare.  Of  three  sisters,  whose  family  life 
was  intimately  known  to  me.  one  had  one  child  only,  a  girl,  whilst 
the  two  others  remained  childless.  The  girl  of  the  second  genera- 
tion married  and  remained  childless.  In  England  it  is  well  estab- 


THE  SEXUAL  EPOCH  OF  THE  MENACME.  487 

lished  that  when,  in  cases  of  only-child-sterility,  the  offspring  is  of 
the  female  sex,  this  child  will  probably  herself  be  barren.  Gallon 
found  that  in  the  case  of  14  heiresses  (i.  e.  the  only  children  of 
wealthy  parents),  all  of  whom  were  married,  8  remained  absolutely 
barren,  whilst  of  the  others,  2  had  each  an  only  child. 

It  was  formerly  believed  that  when  a  woman  gave  birth  to  twins 
of  opposed  sexes,  the  female  infant  would  prove  to  be  barren,  this 
barrenness  being  associated  with  defective  development  of  her  re- 
productive apparatus.  John  Hunter  (Animal  Economy)  ascertained 
that  in  the  case  of  twin  calves  of  opposed  sex,  the  genital  organs 
of  the  female  twin  were  almost  invariably  imperfectly  developed. 
But  the  supposition  that  this  is  true  also  of  the  human  species  has 
not  been  confirmed  by  experience.  I  know  several  married  women 
who  had  twin  brothers,  and  these  women  have  borne  normal  chil- 
dren ;  however,  the  number  of  their  offspring  is  remarkably  small. 
Simpson,  in  Edinburgh,  recorded  the  results  of  the  marriage  of  113 
women  who  had  been  born  with  twin  brothers ;  of  these,  103  had 
proved  fruitful,  and  10  (i.  e.,  about  one  eleventh  of  the  whole) 
barren,  although  of  these  latter  women,  one  had  been  married  up- 
wards of  5  years,  and  the  remaining  9  for  periods  ranging  from 
10  to  40  years.  Simpson  also  gave  the  history  of  four  women 
who  were  all  the  fruit  of  triple  births,  some  of  which  had  consisted 
of  two  boys  and  one  girl,  others  of  two  girls  and  one  boy.  All 
four  of  these  women  were  parous.  Again,  a  woman  who  had  been 
one  of  a  quadruple  birth  (three  boys  and  one  girl),  herself  gave 
birth  to  triplets.  A  collection  of  all  the  figures  accessible  to  me 
relating  to  this  subject,  indicates  that  about  ten  per  cent  of  the 
women  born  in  such  circumstances  prove  barren — a  ratio  which 
corresponds  closely  with  the  ratio  of  infertility  in  general. 

Interference  zvith  Conjugation,  Conditions  Preventing  Access  of  the 
Spermatozoa  to  the  Ovum. 

A  condition  essential  to  fertilization  is  a  material  union  between 
the  sexual  products  of  the  male  and  the  female  respectively — the 
act  of  conjugation.  Thus,  all  conditions  which  prevent  the  sperma- 
tozoa from  obtaining  access  to  the  ova,  bring  about  sterility. 

Spermatozoon  and  ovum  being  normal,  a  great  variety  of  patho- 
logical conditions  may  prevent  the  one  from  gaining  access  to  the 
other.  It  is  necessary  for  fertilization  that  the  mature  ovum  should 
leave  the  ovary,  enter  the  Fallopian -tube,  and  there  come  into  con- 
tact with  the  male  sperm.  Interference  with  any  one  of  these  essen- 
tials may  lead  to  sterility. 

Thus,  the  constitution  of  the  ovum  itself  may  be  at  fault ;  or  the 
entrance  of  the  ovum  into  the  Fallopian  tube  may  not  be  normally 
effected ;  defects  in  these  earliest  stages  of  the  process  of  fertilization 


THE  SEXUAL  LIFE  OF  WOMAN. 

are  precisely  the  commonest  and  the  most  important.  The  emer- 
gence of  the  ovum  from  the  graafian  follicle  may  be  rendered 
difficult  or  entirely  prevented  by  pathological  states  of  the  ovary; 
again,  by  inflammatory  processes  in  the  ovary,  the  tubes,  or  the  liga- 
ments, by  developmental  defects  in  the  tube,  and  by  obstructions  in 
its  interior,  the  entrance  of  the  ovum  into  the  tube,  and  its  free  pas- 
sage along  the  tube  may  be  prevented.  Numerous  abnormalities 
and  diseases  of  the  uterus  may  on  the  one  hand  prevent  the  entrance 
of  the  ovum  in<x>  the  uterine  cavity,  and  on  the  other  may  prevent 
the  upward  passage  of  the  spermatozoa  to  their  goal.  Amongst 
conditions  competent  to  produce  these  effects  we  must  enumerate: 
displacements  of  the  uterus,  structural  changes  in  this  organ  and  its 
annexa,  and  other  congenital  defects  and  acquired  states ;  more 
particularly  must  be  mentioned,  uterus  infantilis,  acquired  atrophy 
of  the  uterus,  flexions  and  versions  of  the  uterus,  new-growths  and 
inflammatory  states  of  that  organ,  abnormalities  in  the  shape  or  size 
of  the  cervix  uteri,  and,  finally,  all  conditions  of  the  vagina  or 
vulva  which  hinder  the  proper  performance  of  the  act  of  intercourse. 

In  diagnosing  the  cause  of  sterility,  in  determining  whether  in 
any  particular  instance  it  is  due  to  some  hindrance  to  the  indispens- 
able conjugation  between  the  male  and  female  reproductive  elements, 
we  have  in  the  first  place  to  ascertain  the  presence  or  absence  of  any 
of  the  numerous  conditions  which  interfere  with  the  proper  passage 
of  the  ovum  from  the  ovary  through  the  Fallopian  tube  to  the 
interior  of  the  uterus.  The  simpler  mechanical  hindrances  to  con- 
ception, such  as  displacements  of  the  uterus,  or  tumours  of  that 
organ  or  its  annexa,  are  easily  recognized ;  and  the  same  is  true 
of  atresia  of  the  cervix  uteri,  and  of  congenital  or  acquired  stenosis 
of  the  vagina.  When  obliteration  or  stricture  of  the  genital  tract 
exists,  a  very  careful  examination,  visual,  digital,  and  instrumental, 
must  be  made,  rectal  examination  not  being  forgotten.  Not  infre- 
quently, amenorrhoea  is  attributed  to  ovarian  disease,  and  only 
subsequently  on  local  examination  is  the  cause  ascertained  to  be 
hymeneal  atresia,  with  haematokolpos ;  many  a  woman  has  believed 
herself  to  be  pregnant,  until  examination  has  disclosed  the  fact  that 
the  hymen  is  still  intact,  and  that  coitus  has  hitherto  been  effected 
through  the  uretha.  The  importance  of  these  stenotic  conditions 
as  causes  of  sterility  must  not,  however,  be  overestimated,  for, 
although  they  are  common  among  the  hindrances  to  conception, 
the  obstacle  is  by  no  means  always  insuperable. 

Morbid  changes  in  the  secretions  of  the  genital  passages,  whereby 
the  vitality  of  the  spermatozoa  may  be  destroyed  before  they  have 
time  to  reach  the  ovum  and  effect  fertilization,  are  hard  to  diagnose, 
for  the  conditions  upon  which  such  changes  depend  have  not  as  yet 
been  adequately  investigated. 


THE  SEXUAL  EPOCH  OF  THE  MENACME.  489 

Diseases  of  the  Ovaries  and  the  Fallopian  Tubes. 

Among  the  conditions  which,  although  the  maturation  of  the  ovum 
proceeds  normally  to  a  conclusion,  may  prevent  conjugation  between 
the  male  and  female  elements,  we  must  in  the  first  place  consider 
an  abnormal  condition  of  the  tunica  albuginea  of  the  ovary,  a 
thickening  of  this  membrane  in  consequence  of  inflammatory  pro- 
cesses or  of  new  formation  of  connective  tissue,  whereby  the  dehi- 
scence  of  the  follicle  is  rendered  difficult  or  entirely  prevented. 
Such  thickenings  of  the  ovarian  envelope  are  the  residue  of  peri- 
oophoritic  processes. 

Such  a  hindrance  to  conception  may  be  permanent  or  transient, 
and  thus  the  sterility  dependent  thereupon  may  be  relative  or  abso- 
lute. Similar  is  the  effect  of  inflammatory  processes  affecting  the 
peritoneal  investment  of  the  uterus,  the  broad  .ligaments,  and  the 
peritoneum  clothing  the  floor  of  the  pelvis;  these  conditions,  peri- 
metritis,  perisalpingitis,  and  pelvic  peritonitis,  resulting  in  the  forma- 
tion of  thick  and  extensive  pseudomembranous  bands,  or  in  less 
severe  cases  leaving  merely  slight  adhesions  and  filaments,  which 
drag  the  uterus  and  the  ovaries  out  of  place,  and  thus  render  con- 
ception difficult  or  impossible. 

Perimetritic  adhesions  are  apt  to  lead  to  dislocation  of  the  tubes 
either  forwards  or  backwards,  and  most  commonly  into  the  pouch 
of  Douglas,  thus  giving  rise  to  sterility.  Rokitansky  and  Virchoiv 
already  insisted  on  the  great  importance  of  perimetritic  processes 
in  causing  sterility. 

That  congenital  defects  of  the  Fallopian  tubes  may  lead  to  steril- 
ity, is  indeed  a  possible,  but  certainly  a  rare  occurrence.  The 
defect  may  be  unilateral  or  bilateral;  or  it  may  be  that  merely  a 
portion  of  one  tube  may  be  wanting.  Bilateral  absence  of  the  Fal- 
lopian tubes  is  usually  associated  with  defective  development  of  the 
uterus,  while  the  ovaries  may  be  apparently  normal.  Such  a  case 
is  described  by  Foerster  and  Kussmaul.  The  vagina  opened  into 
the  uretha,  the  uterus  was  not  calibrated,  and  diverged  above  into 
two  solid  horns,  to  which  the  round  ligaments  and  the  ovaries  were 
atached.  A  congenital  cause  of  sterility  is  to  be  found  also  in 
atresia  of  the  tubes,  the  abdominal  extremities  of  which  are  closed; 
this  condition  is  met  with  also  in  other  mammals.  It  is  also  assumed, 
with  less  accuracy,  that  a  supernumerary  ostium  tubae  may  lead 
to  sterility,  in  consequence  of  the  ovum,  which  has  found  its  way 
into  the  normal  ostium,  returning  into  the  abdominal  cavity  through 
the  supernumerary  orifice.  An  unfavourable  influence  upon  fertility 
is  exercised  also  by  a  form  of  hyperplasia  of  the  tubes  which  some- 
times arises  in  consequence  of  erroneous  development  at  the  time 
of  puberty ;  the  tubes,  increasing  unduly  in  length,  become  serpen- 


490  THE  SEXUAL  LIFE  OF  WOMAN. 

tine  in  form  instead  of  being  nearly  straight ;  this  tends  to  lead  to 
accumulation  of  the  secretions,  and  renders  the  passage  of  the  ovum 
difficult.  (Frcund.)  Yet  another  defect  of  development  which,  as 
Klebs  has  pointed  out,  may  lead  to  sterility,  is  absence  of  the  fimbria 
which  normally  retains  the  abdominal  orifice  of  the  Fallopian  tube 
in  proximity  with  the  ovary,  in  which  case  these  structures  may 
be  separated  by  a  wide  interval. 

The  entry  of  the  ovum  into  the  tube  may  thus  be  rendered  difficult 
by  abnormalities  of  the  abdominal  orifice  of  the  tube  or  of  the  fim- 
briae ;  but  still  more  is  this  the  case  when  the  mucous  membrane 
of  the  tube  is  diseased.  The  fringed  border  of  the  tubal  orifice  has 
a  distinct  tendency  to  independent  disease.  As  Klebs's  anatomico- 
pathological  studies  have  shown,  inflammatory  changes  are  common 
in  this  region,  leading  to  contraction.  The  free  margin  of  the 
tube  then  appears  to  be  strictured  by  over-growth  of  fibrous  tissue 
on  the  serous  surface,  the  opening  being  thus  narrowed  or  even 
entirely  closed,  whilst  the  fimbriae  themselves  may  be  drawn  within 
the  aperture.  In  other  cases,  the  ring  of  fimbriae  is  adherent  to 
some  neighbouring  part,  especially  to  the  ovary  itself,  when  this 
also  is  diseased.  Further,  on  the  fringed  margin  of  the  tube  we 
see  papillary  growths,  telangiectases,  or  oedema  with  formation  of 
cystic  cavities. 

In  the  interior  of  the  tubes  also,  pathological  processes  occur, 
catarrhal  inflammations,  haemorrhagic  or  purulent  exudations,  seal- 
ing up  the  passage  completely.  In  some  cases  these  exudations  lead 
to  great  distension  and  even  to  rupture  of  the  tube.  Thus,  among 
the  causes  of  sterility  must  be  enumerated:  simple  catarrh  of  the 
tube,  with  swelling  of  the  mucous  membrane:  purulent  catarrh, 
leading  to  its  distension  with  pus  —  pyosalpinx;  serous  effusion 
into  the  tube,  hydrosalpinx ;  and  haemorrhagic  effusion,  haemato- 
salpinx ;  further,  that  peculiar  form  of  tubal  inflammation,  described 
by  Chiari  and  Schauta  under  the  name  of  salpingitis  isthmica  nodosa, 
in  which  hyperplasia  of  the  muscular  coat  of  the  tube  occurs  at 
irregular  intervals,  so  that  it  appears  to  be  beset  with  nodes.  Special 
mention  must  also  be  made  of  gonorrhoeal  salpingitis,  which  will 
subsequently  be  described  in  detail. 

Inflammatory  states  of  the  tube  may  hinder  conception,  either 
mechanically,  by  swelling  of  the  mucous  membrane,  or  by  obstruc- 
tion of  the  lumen  of  the  tube  by  exudations,  by  injury  or  destruction 
of  the  ciliated  epithelium,  by  lesion  of  the  musculature  of  the 
tube,  affecting  its  peristaltic  movements  —  all  these  hindering  or 
entirely  preventing  the  passage  of  the  ovum  downwards  or  of  the 
spermatozoa  upwards;  or,  again,  chemically,  by  the  deleterious  in- 
fluence of  many  of^  the  morbid  secretions  that  are  formed  in  these 
conditions  upon  the  vitality  of  ova  or  spermatozoa.  These  inflam- 


THE  SEXUAL  EPOCH  OF  THE  MENACME.  491 

matory  states  of  the  tubes  may  also  lead  to  stricture  or  obliteration 
of  their  abdominal  extremities,  or  to  displacement  of  the  ostia,  and 
thus  lead  to  sterility ;  in  other  cases  these  same  conditions,  leading 
to  distortion  and  displacement  of  the  tube,  may  prevent  the  down- 
ward passage  of  the  ovum  while  leaving  possible  the  upward  passage 
of  the  spermatozoa,  and  thus  give  rise  to  tubal  gestation  —  a  con- 
dition which  we  shall  not  now  consider. 

It  must  not  be  forgotten  that  tuberculosis  of  the  genital  canal 
attacks  the  tubes  with  especial  frequency ;  in  these  organs  we  may 
find  miliary  tubercles,  and  more  commonly  diffuse  caseous  masses, 
completely  filling  the  lumen  of  the  canal.  Finally  we  have  to  men- 
tion the  diverse  forms  of  saccular  dilatation  of  the  tubes  (Ger. 
"  Tubensacke"},  all  of  which  possess  the  common  pathological  char- 
acteristics of  enlargement  of  the  tubes  and  their  conversion  into  sac- 
cular cavities ;  the  contents  of  these  distended  tubes  may,  however, 
be  extremely  various,  and  such  conditions  may  depend  upon  mani- 
fold mechanical  disturbances  and  inflammatory  processes  of  the 
uterus  and  its  annexa. 

When  we  consider  how  common,  during  the  sexual  life  of  women, 
are  perioophoritic  inflammations,  more  or  less  intense,  but  often 
without  severe  symptoms  (and  hence  apt  to  be  overlooked)  ;  when 
we  remember  that  the  very  process  of  ovulation  and  also  the  puer- 
peral state  furnish  opportunities  for  slight  or  severe  pelvic  perito- 
nitis to  arise ;  and  when  we  further  take  into  account  the  frequency 
and  importance  of  gonorrhoeal  pelvic  peritonitis  —  we  cannot  fail 
to  admit  that  the  results  of  these  morbid  conditions,  such  as  adhe- 
sions between  the  ovary  and  the  ostium  tubae,  or  closure  of  the  tube 
with  consequent  hydro  or  pyosalpinx,  must  be  reckoned  among  the 
principal  causes  of  sterility.  If  the  frequency  and  importance  of 
these  conditions  is  still  underestimated,  two  reasons  can  be  adduced 
for  this:  first,  that  the  slighter  degrees  of  intrapelvic  inflammation 
often,  as  previously  mentioned,  elude  diagnosis ;  and,  secondly,  that 
even  when  the  treatment  is  expectant  merely,  the  exudations  are 
frequently  absorbed,  the  adhesions  give  way,  and  the  capacity  for 
conception  is  gradually  fully  restored. 

When  considering  the  etiology  of  acquired  sterility,  especial  atten- 
tion must  be  devoted  to  gonorrhoeal  pyosalpinx,  the  most  important 
and  the  most  dangerous  of  the  morbid  manifestations  of  gonorrhoeal 
infection  in  the  female.  Gonorrhoeal  salpingitis  and  perisalpingitis 
are  very  serious  affections,  in  the  first  place  because  they  are  apt  to 
give  rise  to  oophoritis  and  perioophoritis,  as  well  as  to  pelvic  perito- 
nitis, and  other  local  inflammatory  states.  The  minuteness  of  the 
uterine  orifice  of  the  Fallopian  tube,  and  the  downward  direction  of 
the  ciliary  movement  in  the  interior  of  the  tube,  combine  to  safe- 
guard against  the  entrance  of  gonococci,  but  none  the  less  they  too 


492  THE  SEXUAL  LIFE  OF  WOMAN. 

often  find  their  way  up  the  tube,  and  small  quantities  of  gonorrhoeal 
pus  enter  the  pelvic  cavity  and  give  rise  to  inflammations,  in  which 
the  ovary  partakes. 

According  to  Sacnger,  this  gonorrhoeal  disease  of  the  uterine  an- 
nexa  is  found  with  especial  frequency  in  women  either  wholly  ster- 
ile or  affected  with  only-chikl-sterility,  and  is  to  be  regarded  as  the 
cause  of  their  infertility ;  "  infertility  is  indeed  the  rule,  fertility  the 
exception,  in  all  cases  in  which  gonorrhoeal  disease  has  passed 
upwards  beyond  the  os  uteri  externum."  The  same  author  main-, 
tains  that,  putting  aside  tuberculosis  and  actinomycosis,  if,  in  a  case 
of  infective  inflammation  of  the  uterine  annexa,  septic  infection  can 
be  excluded,  and  more  especially  when  the  disease  affects  both  tubes, 
when  it  is  reluctant  to  yield  to  treatment,  and  when  relapses  are 
frequent,  we  have  no  option  but  to  believe  that  the  affection  is  of 
gonorrhoeal  origin. 

•In  155  cases  of  chronic  inflammatory  disease  of  the  Fallopian 
tubes,  von  Rostliorn  was  able  in  37  instances  to  prove  that  the 
affection  was  the  direct  result  of  gonorrhoeal  infection. 

Recently,  however,  Noble  has  published  cases  which  lead  us  to 
believe  that  even  pyosalpinx  does  not  necessarily  prevent  the  oc- 
currence of  pregnancy.  In  operating  for  the  relief  of  a  unilateral 
pyosalpinx,  the  uterus  was  opened,  and  a  seven  months'  foetus  was 
removed.  In  another  case,  the  autopsy  on  a  woman  who  had  suc- 
cumbed to  severe  peritonitis  arising  immediately  post  partum,  dis- 
closed a  large  pyosalpinx. 

Closure  of  the  ostium  may  also  be  brought  about  by  chronic 
metritis  and  endometritis,  by  chronic  catarrahal  states  of  the  uterine 
mucous  membrane,  and  in  general  by  pathological  changes  in 
that  membrane  associated  with  local  hyperaemia  or  abnormal 
secretions.  In  some  cases,  salpingitis  with  consequent  ster- 
ility is  the  result  of  puerperal  infection ;  and  such  a  sequence  of 
events  is  especially  common  after  an  abortion  followed  by  retro- 
flexion  of  the  uterus,  leading  to  elongation  and  kinking  of  the  tubes. 

An  important  hindrance  to  the  entry  of  the  ovum  into  the  uterus 
is  sometimes  offered  by  uterine  polypi  or  myomata;  growing  from 
the  fundus,  these  may  so  fill  the  uterine  cavity  that  the  uterine 
orifices  of  the  tubes  appear  to  be  completely  occluded. 

At  times,  also,  quite  small  myomata,  growing  close  to  the  tubes, 
may  push  these  latter  upwards,  closing  them,  and  thus  giving  rise 
to  sterility  ;  such  myomata  may  also  lead  to  saccular  dilatation  of  the 
tubes,  as  occurred  in  the  following  case: 

Mrs.  S.,  aged  39  years,  had  one  child  when  20  years  of  age,  but 
since  then  had  been  barren.  For  several  years  she  had  suffered  from 
profuse  menorrhagia.  Owing  to  the  enormous  thickening  of  the 
abdominal  wall,  bimanual  examination  of  the  uterus  was  impossible; 


THE  SEXUAL  EPOCH  OF  THE  MENACME.  49$ 

the  vagina  was  relaxed,  enlarged,  and  contained  an  excess  of  mu- 
cous secretion.  The  uterus  was  high  up  in  the  pelvis,  anteverted, 
enlarged,  movable,  sensitive  to  pressure ;  the  portio  vaginalis  was 
enlarged,  soft,  and  excoriated ;  no  tumour  could  be  detected  either 
in  the  uterus  or  in  the  uterine  annexa.  The  menstrual  flow  recurred 
at  intervals  of  from  two  to  three  weeks,  lasting  from  one  to  two 
weeks,  and  being  extremely  profuse ;  menstruation  was  painful. 
Whilst  the  patient  was  under  my  observation  an  excessive  menstrual 
haemorrhage  came  on  quite  suddenly,  with  slight  rise  of  evening 
temperature  (38.2°  C. —  100.8°  F.),  but.  severe  general  disturbance; 
there  were  paroxysms  of  intense  abdominal  pain,  violent  vomiting 
of  greenish  bilious  masses,  which  after  a  time  became  haemor- 
rhagic,  the  abdomen  was  tense  and  sensitive  to  pressure,  there  was 
cardiac  weakness  with  general  failure  of  strength ;  treatment  proved 
unavailing,  and  the  patient  died  in  collapse  on  the  third  day.  The 
autopsy  disclosed :  fibroma  uteri  submucosum,  parietale,  et  subser- 
osum,  haematosalpinx  dextra,  pyosalpinx  sinistra,  peritonitis.  The 
subserous  myoma,  of  about  the  size  of  a  pea,  was  in  the  middle  of 
the  fundus  uteri ;  the  submucous  myoma,  of  about  the  size  of  a 
chestnut,  filling  the  uterine  cavity,  sprang  from  the  posterior  wall  of 
the  body  of  the  uterus ;  the  intramural  myoma,  of  about  the  size  of 
a  bean,  was  in  the  right  wall  of  the  corpus  uteri.  Both  tubes  were 
greatly  elongated,  exhibiting  serpentine  windings.  The  right  tube 
was  much  distended,  filled  with  sanguineous  fluid ;  the  left,  partially 
collapsed,  contained  greyish-green  purulent  material,  having  an  ex- 
tremely offensive  odour;  some  of  this  fluid  had  flowed  through 
the  ostium  abdominale  into  the  abdominal  cavity.  Death  in  this  case 
ensued  with  great  rapidity  in  consequence  of  rupture  of  the  pyosal- 
pinx, and  evacuation  of  its  contents  into  the  abdominal  cavity. 

Cystic  formations  in  the  round  ligament  (hydrocele  of  the  round 
ligament)  sometimes  lead  to  sterility.  In  the  form  of  elongated 
tumours  of  about  the  size  of  a  hen's  egg  they  may  fill  the  inguinal 
canal,  and  even  pass  forwards  into  the  labia  majora.  When  as 
large  as  this,  they  demand  operative  interference.  Hennig  records 
a  case  in  which  such  hydrocele  of  the  round  ligament  was  the  cause 
of  sterility  lasting  14  years,  the  woman  becoming  pregnant  after 
the  tumour  had  been  removed  by  operation.  Similarly,  infertility 
may  depend  upon  solid  tumours  of  the  round  ligaments  —  myomata, 
fibromyomata,  or  sarcomata. 

Retro-uterine  haematocele  often  gives  rise  to  sterility.  As  a  rule, 
prior  to  the  formation  of  a  blood-tumour  in  the  pouch  of  Douglas, 
various  menstrual  disturbances  occur,  more  especially  menorrhagia ; 
or  it  may  be  preceded  by  some  puerperal  disease,  especially  peri- 
metritis,  which  by  itself,  indeed,  seriously  limits  the  fertility  of  the 
woman  thus  affected ;  but  when  haematocele  is  superadded,  her  child- 


494  THE  SEXUAL  LIFE  OF  WOMAN. 

bearing  capacity  is  much  more  gravely  impaired,  owing  to  the  per- 
manent displacement  of  the  uterus,  to  the  perimetritic  exudations, 
to  the  adhesions  formed  around  the  ovary,  and  to  stricture  or  oc- 
clusion of  the  tubes.  Still,  sterility  is  by  no  means  an  inevitable 
consequence  of  haematocele. 

By  many  it  is  assumed  that  in  cases  in  which  the  tubes  are  per- 
fectly normal,  disturbances  of  innervation  are  competent  to  cause 
sterility  (or  tubal  gestation).  It  is  supposed  that  nervous  influences 
affect  the  functions  of  the  Fallopian  tubes  by  leading  to  spastic 
contractures  of  the  circular  muscular  fibres  of  these  structures,  or 
in  other  cases  to  paralysis ;  in  this  way  nervous  disorder  may  lead 
to  the  retention  within  the  tube  of  the  unfertilized  (or  already  fertil- 
ized) ovum. 

Diseases  of  the  Uterus. 

Pathological  changes  in  the  uterus  may  in  various  ways  lead  to 
sterility  dependent  upon  prevention  of  conjugation  (physical  con- 
tact of  the  male  and  female  reproductive  elements).  Thus,  the 
incapacity  for  fertilization  may,  on  the  one  hand,  depend  on 
hindrances  to  the  passage  of  the  ovum  from  the  tube  to  the  in- 
terior of  the  uterus ;  or  on  the  other,  on  some  abnormal  condition 
of  the  vaginal  portion  of  the  cervix,  whereby  the  passage  of  the 
spermatozoa  from  the  vagina  into  the  uterus  is  prevented ;  or,  finally, 
upon  displacements  of  the  uterus  or  pathological  structural  changes 
in  that  organ,  whereby  the  implantation  of  the  fertilized  ovum  in 
the  uterine  cavity  and  its  development  therein  are  impeded. 

The  uterus  may  be  entirely  absent,  but  this  is  an  extremely  rare 
condition;  much  less  infrequent  is  a  rudimentary  condition  of  that 
organ.  In  the  latter  case,  it  is  either  represented  by  a  nodular  rudi- 
ment, or  else  it  is  conical  or  bicorned ;  whatever  its  shape,  it  is  a 
solid  mass  of  muscular  and  connective  tissue.  In  association  with 
absence  or  a  rudimentary  condition  of  the  uterus,  the  vagina  also 
may  be  wanting,  or  may  be  represented  merely  by  a  small,  blind 
pouch ;  the  Fallopian  tubes  may  in  such  cases  either  be  normally 
developed  or  rudimentary.  The  number  of  instances  of  this  kind 
that  have  been  observed  is  very  large  (Kussmaul,  Klebs,  Cusco, 
Klinkosch-Hill,  Cruise,  Frcund,  Filrst,  Engel,  Gilsserow,  Nega, 
Kiwisch,  Rokitansky,  Braid,  Jackson,  Lucas,  Duplay,  Dnpiiytreu, 
Rcnauldin,  Crcdc,  Saexinycr,  and  many  others). 

The  uterus  and  the  vagina  may  be  absent  in  cases  in  which  the 
vulva  is  developed  in  a  perfectly  normal  manner,  with  a  mons 
veneris  projecting  as  usual,  and  covered  with  a  proper  growth  of 
hair.  Ormerod  and  Quain  have  reported  cases  of  this  kind,  in 
which  the  external  sexual  characters  were  those  of  a  fully  mature, 
perfectly  developed  woman,  but  in  whom  the  uterus  and  ovaries 
were  entirely  wanting. 


THE  SEXUAL  EPOCH  OF  THE  MENACME.  495 

These  defects  of  development  necessarily  entail  complete  sterility. 
Sometimes  during  life  the  cause  of  the  sterility  is  entirely  over- 
looked, and  only  discovered  by  chance  or  in  post  mortem  examina- 
tion. Although  the  vagina  usually  shares  to  a  marked  extent  in  the 
defects  of  the  uterus,  and  at  puberty  undergoes  a  rudimentary  de- 
velopment merely,  the  marital  intercourse  of  such  individuals  com- 
monly appears  to  be  perfectly  normal.  As  a  result  of  frequently 
repeated  and  vigorous  attempts  at  intercourse,  the  rudimentary 
vagina  becomes  accommodated  to  the  needs  of  the  case;  and  even 
when  the  vagina  is  absent,  the  rudimentary  depression  by  which 
it  is  represented  becomes  distended  into  a  large  blind  sac  capable 
of  accommodating  the  erect  penis.  In  other  such  cases,  the  penis 
finds  for  itself  some  abnormal  channel,  and  the  husband  may  con- 
tinue to  indulge  in  intercourse  for  a  long  period  without  discovering 
that  there  is  anything  unusual.  Sometimes  it  is  the  urethra  which 
becomes  dilated  and  takes  on  in  part  the  function  of  the  vagina; 
in  other  cases  intercourse  is  effected  per  anum. 

The  following  most  remarkable  case  came  under  my  own  observa- 
tion. The  patient's  husband  was  a  physician,  who  nevertheless  was 
in  complete  ignorance  of  his  wife's  abnormalities.  The  woman  was 
26  years  of  age,  of  medium  stature,  somewhat  obese,  breasts  moder- 
ately well  developed,  pubic  hair  well  grown.  She  stated  that  before 
marriage  she  had  menstruated  regularly,  and  that  it  was  only  after 
she  had  married  four  years  previously  that  menstruation  had  ceased 
—  statements  which  were  unquestionably  false.  She  consulted  me 
on  account  of  amenorrhoea  and  sterility,  which  her  husband  believed 
to  depend  upon  her  increasing  obesity.  Examination  showed  that 
the  vagina  admitted  two  fingers  and  was  10  cm.  (4")  in  length; 
but  it  was  completely  blind,  and  the  mucous  membrane  was  strik- 
ingly smooth.  On  bimanual  examination,  only  a  rudiment  of  the 
uterus  could  be  detected,  a  mass  no  larger  than  a  hazel-nut;  the 
ovaries  could  not  be  felt. 

A  similar  case  is  recorded  by  Heppncr.  A  Finnish  peasant 
woman  31  years  of  age  consulted  him  on  account  of  amenorrhoea 
and  sterility.  She  had  been  married  for  12  years,  and  neither  before 
marriage  nor  since  had  menstruated  or  had  had  any  periodic  vi- 
carious bleeding.  The  pubes  and  the  labia  majora  were  thinly 
covered  with  hair ;  the  latter  were  very  flaccid  and  but  slightly 
prominent;  the  nymphae  hung  down  like  an  apron  for  as  much  as 
an  inch  below  the  genital  fissure,  and  were  very  thin;  the  clitoris 
was  but  slightly  developed.  The  urethral  papilla  was  of  normal 
size,  the  lacunae  around  it  were  extremely  well  marked ;  the  urethral 
orifice  had  the  form  of  a  zigzag  slit.  Behind  this  latter  was  an 
aperture  environed  by  radiating  folds,  and  this  was  the  entrance  to 


496  THE  SEXUAL  LIFE  OF  WOMAN. 

a  blind  passage  about  two  inches  in  length ;  this  aperture  could 
not,  however,  be  identified  as  the  introitus  vaginae,  for  the  reason 
that  there  were  no  carunculae  myrtiformes,  and  moreover  the  cal- 
losity of  the  mucous  membrane  characteristic  of  the  vaginal  orifice 
was  wanting.  Behind  the  strongly  projecting  commissura  labiorum, 
however,  the  fossa  navicularis  appears  as  a  separate  depression. 
The  blind  passage  was  clothed  with  a  soft,  pale-red  mucous  mem- 
brane, and  was  entirely  devoid  of  any  trace  of  columnae  rugarum ; 
at  the  extremity  of  this  passage  there  was  neither  scar  nor  indura- 
tion. On  rectal  exploration,  no  trace  of  uterus,  normal  vagina,  or 
ovaries  could  be  felt,  notwithstanding  the  fact  that  the  abdominal 
walls  were  very  flaccid  and  examination  was  therefore  easy.  The 
general  configuration  was  feminine,  the  breasts  were  flabby  and 
dependent,  the  waist  and  hips  were  those  of  a  woman. 

Tanffcr  reports  the  case  of  a  woman  25  years  of  age,  married  2l/t 
years,  absolutely  amenorrhoeic ;  on  examination  she  was  found  to 
have  atresia  vaginae  with  rudimentary  development  of  the  uterus. 
The  breasts  were  small,  the  mons  veneris  was  deficient  in  fat,  but 
thickly  covered  with  hair,  the  labiae  and  the  clitoris  were  normal. 

R.  Leri  describes  a  case  in  which,  in  a  patient  19  years  of  age, 
the  uterus  was  wanting,  though  the  general  physical  development 
was  that  of  a  normal  woman.  The  breasts  were  well  formed,  and  so 
also  were  the  external  genital  organs ;  a  blind  passage  4  cm.  (1.6  in.) 
in  length,  and  admitting  two  fingers,  represented  the  vagina.  In 
the  position  normally  occupied  by  the  ovaries,  were  two  bodies 
which  were  doubtless  the  rudiments  of  these  organs.  Menstrual 
molimina  had  never  been  experienced. 

yon  Hoffmann,  in  making  a  post  mortem  examination  on  an 
elderly  married  woman,  found  that  the  vagina  ended  blindly  at  a 
depth  of  6  cm.  (2.4  in.),  whilst  the  uterus  was  represented  merely 
by  a  pyramidally  arranged  bundle  of  fibres  in  the  broad  ligament. 
Lissner  reports  a  case  in  which  the  physician  was  the  first  to  draw 
the  husband's  attention  to  the  fact  that  his  wife  had  no  uterus. 

Ziehl,  in  a  married  woman  57  years  of  age,  found  that  the  uterus 
was  completely  wanting;  the  vagina  ended  blindly  half  an  inch 
from  the  surface;  the  tubes  and  ovaries  were  present.  Boyd,  in  a 
married  woman  72  years  of  age,  found  a  blind  vagina  half  an  inch 
in  length,  and  the  uterus  represented  by  a  nodular  rudiment  on  the 
posterior  wall  of  the  bladder. 

Rare  cases  are  also  recorded  in  the  literature  of  the  subject,  in 
which,  notwithstanding  the  absence  of  the  uterus,  normal  ovaries 
were  present,  and  in  these  latter  periodic  ripening  of  the  graafian 
follicles  took  place.  A  case  of  this  kind  was  described  by  Burg- 
gracve. 

Complete  sterility  is  entailed  also  by  a  persistence  of  the  foetal 


THE  SEXUAL  EPOCH  OF  THE  MENACME.  497 

condition  of  the  uterus.  In  these  cases,  the  uterus  retains  the  form 
it  possessed  at  the  beginning  of  the  second  half  of  intra-uterine  life. 
The  portio  vaginalis  projects  but  slightly  into  the  vagina,  and  the 
os  uteri  externum  appears  as  a  small  rounded  opening  The  cervix 
is  comparatively  long  and  wide,  and  the  folds  on  the  mucous  mem- 
brane of  the  cervical  canal  are  fully  formed.  The  body  of  the 
uterus  is  imperfectly  developed,  triangular  in  shape,  with  thin. walls; 
it  is  shorter  than  the  cervix,  and  its  interior  is  marked  by  folds  of 
mucous  membrane  converging  towards  the  os.  In  these  cases 
menstruation  is  absent  or  scanty ;  the  other  reproductive  organs, 
including  the  breasts,  are  usually  in  a  state  of  arrested  development. 
Women  with  foetal  uterus  are  capable  of  sexual  intercourse,  and 
carry  on  most  of  the  functions  of  their  sexual  life  in  a  manner 
apparently  normal ;  they  are,  however,  invariably  sterile. 

An  analogous  cause  of  sterility  is  presented  by  the  condition 
known  as  uterus  infantilis,  in  which  at  puberty  the  uterus  fails  to 
undergo  the  changes  proper  to  this  period,  and  remains  in  the  con- 
dition characteristic  of  infancy.  The  cervix  is  disproportionately 
large,  whilst  the  body  of  the  uterus  is  cylindrical  in  form,  and  the 
mucous  membrane  lining  its  cavity  is  always  smooth.  The  muscular 
substance  is  unduly  thin.  The  vagina  may  be  normal,  sometimes, 
however,  it  is  narrow,  and  the  mucous  membrane  is  less  rugose  than 
normal.  Associated  with  an  infantile  condition  of  the  uterus  we 
find  commonly,  but  by  no  means  invariably,  imperfect  development 
of  the  external  genital  organs,  the  labia,  the  clitoris,  and  the  vagina ; 
the  mons  veneris  is  but  thinly  covered  with  hair;  the  breasts  are 
small.  As  a  rule,  menstruation  is  entirely  wanting.  Occasionally 
the  ovaries  are  wanting.  This  infantile  condition  of  the  uterus  is 
by  no  means  extremely  rare.  According  to  Beigel's  figures,  among 
155  sterile  women,  in  four  the  uterus  was  infantile. 

Among  200  cases  of  sterility  in  which  it  was  possible  for  me  to 
make  a  searching  enquiry  for  the  cause,  I  found  16  instances  of 
infantile  uterus.  Neither  in  the  general  physical  configuration  of 
these  women,  nor  in  the  state  of  their  menstrual  functions,  was  there 
any  striking  abnormality ;  in  the  condition  of  the  external  genital 
organs,  however,  in  cases  of  defective  development  of  the  uterus 
and  ovaries,  certain  striking  peculiarities  were,  in  my  experience, 
almost  invariable,  and  deserving  therefore  of  close  attention.  The 
mons  veneris  was  extremely  small,  sometimes  completely  bald,  or 
covered  very  thinly  with  hair;  and  the  hair  when  present,  did  not 
exhibit  the  curliness  usually  seen  in  the  pubic  hair  of  married 
women.  On  examination,  the  uterus,  small  in  all  its  diameters  from 
arrest  of  development,  could  in  every  case  be  detected. 

How  exceptional  it  is  in  adult  females  with  well  developed  internal 
reproductive  organs  for  the  pubic  hair  to  be  scanty  or  completely 
32 


498  THE  SEXUAL  LIFE  OF  WOMAN. 

wanting,  has  been  shown  by  the  investigation  recently  made  by  R. 
Bergh  on  this  hitherto  neglected  subject.  In  2200  individuals  en- 
gaged in  clandestine  prostitution,  he  found  the  pubic  hair  extremely 
scanty  in  148,  and  the  genital  region  nearly  or  completely  bald  in  6. 
He  states  that  early  vigorous  growth  of  the  pubic  hair  is  a  trust- 
worthy sign  of  early  sexual  development;  but  he  remarks  that  the 
opinion  of  Aristotle  that  women  in  whom  the  pubic  hair  is  slight  or 
absent  are  always  sterile,  is  erroneous. 

NOTE. — The  author's  statement  regarding  the  extreme  infrequency  of 
absence  or  deficiency  of  the  pubic  hair  in  women  with  properly  developed 
internal  reproductive  organs,  while  true  of  European  women,  does  not  apply 
to  all  races.  In  Japanese  women,  for  instance,  the  pubic  hair  is  as  a  rule 
much  scantier  than  in  European  women ;  and  baldness,  complete  or  nearly 
complete,  of  the  mons  veneris  is  by  no  means  uncommon.  It  is  the  excep- 
tion, in  Japanese  prostitutes,  to  find  a  thick  and  vigorous  growth  of  genital 
hair. — Transl. 

In  the  Talmud,  there  is  an  interesting  reference  to  this  subject, 
to  the  effect  that  it  may  be  assumed  that  a  woman  is  sterile  if  by  the 
2Oth  year  of  her  life  the  pubic  region  be  not  yet  covered  with  hair, 
if  the  breasts  be  not  developed,  if  coitus  be  difficult,  and  if  the  tone 
of  the  voice  be  masculine. 

Madame  Boivin,  Dugcs,  Lumpe,  and  Pfau,  maintain  that  the 
development  of  the  uterus  from  the  infantile  condition  to  that 
characteristic  of  the  sexually  mature  virgin,  often  occurs  very  late 
and  very  slowly ;  and  that  women  in  whom  we  find  the  uterus  in  an 
infantile  condition,  may  later  begin  to  menstruate  and  may  become 
pregnant.  It  has  been  suggested  that  in  these  cases  there  has  been 
confusion  with  primary  acquired  atrophy  of  the  uterus.  Still,  that 
it  is  necessary  to  be  most  cautions  in  cases  of  infantile  uterus  in 
asserting  that  a  woman  is  permanently  sterile,  has  recently  been 
forcibly  impressed  on  me  by  a  remarkable  instance.  A  married 
woman  consulted  me  some  years  ago  on  account  of  amenorrhoea 
and  sterility ;  examination  showed  clearly  that  the  uterus  was  in  the 
infantile  condition,  and  for  this  reason,  not  I  alone,  but  several 
leading  gynecologists,  assured  her  that  there  was  no  hope  of  her 
ever  becoming  a  mother ;  recently,  however,  after  ten  years  of  ster- 
ile wedlock,  she  was  safely  delivered  of  a  healthy  child. 

A  sub-variety  is  constituted  by  the  uterus  pubescens,  a  uterus 
which  indeed  at  puberty  has  undergone  a  certain  degree  of  de- 
velopment, but  has  failed  to  attain  the  normal  size ;  in  such  cases 
the  menses  are  regular,  but  sometimes  painful.  This  form  of 
arrest  of  development  of  the  uterus  may  occasion  sterility,  which, 
however,  often  proves  curable  when  by  frequent  sexual  intercourse 
and  the  congestion  dependent  thereon,  the  genital  organs  have  been 
stimulated  to  the  completion  of  the  process  of  development ;  the 


THE  SEXUAL  EPOCH  OF  THE  MENACME.  499 

muscular  strength  of  the  uterus  then  becomes  adequate,  and  the 
dysmenorrhoeic  troubles  disappear.  In  general  it  may  be  said  that 
if  the  rudimentary  or  imperfectly  developed  uterus  is  at  all  competent 
to  carry  out  the  function  of  gestation,  the  necessary  changes  some- 
times occur  in  the  organ  with  remarkable  rapidity,  and  result  in 
normal  pregnancy  and  parturition. 

Uterus  unicornis,  when  occurring  alone,  and  not  associated  with 
other  defects  or  errors  in  development,  is  not  a  cause  of  sterility. 
Women  with  a  uterus  unicornis,  with  or  without  an  accessory  horn, 
menstruate,  conceive,  and  pass  through  pregnancy  and  parturition, 
in  a  perfectly  normal  manner;  indeed,  some  women  with  this  de- 
velopmental defect  have  given  birth  to  twins.  The  assumption  that 
uterus  unicornis  predisposes  to  abortion  does  not  always  hold  good. 
If,  however,  pregnancy  occurs  in  a  rudimentary  horn,  rupture  of  the 
membranes  is  inevitable,  and  the  ovum  or  embryo  passes  into  the 
abdominal  cavity,  with  the  usual  accompaniment  of  fatal  haemor- 
rhage. The  rupture  commonly  occurs  between  the  third  and  the 
fourth  month  of  foetal  life  (months  of  four  weeks  each). 

The  uterus  bicornis,  with  which  may  or  may  not  be  associated 
duplication  of  the  vagina,  does  not  as  a  rule  offer  any  hindrance 
to  conception ;  and  the  same  statement  is  true  also  of  the  uterus 
bilocularis  or  septus.  Women  with  these  defects  of  development 
may  give  birth  to  healthy  children ;  and  some  such  women  have  had 
twins,  each  foetus  occupying  a  separate  half  of  the  uterus.  Still, 
births  in  cases  of  double  uterus  and  vagina  are  rare  occurrences. 
Such  cases  have  been  published  by  Las  are  wit  sch,  Litschkus,  and 
Keszmarsky.  In  very  rare  cases  of  uterus  bicornis  associated  with 
double  vagina,  an  obstacle  to  conception  is  offered  by  the  fact  that 
one  side  only  of  the  double  vagina,  the  larger,  is  utilized  in  sexual 
intercourse,  and  that  this  is  a  blind  passage. 

In  cases  of  uterus  bilocularis  seu  septus,  the  conditions  as  regards 
pregnancy  and  parturition  are  similar  to  those  that  obtain  in  cases 
of  uterus  bicornis.  The  twin  uterus,  uterus  didelphys,  the  condition 
in  which  the  uterus  is  represented  by  two  completely  separated 
halves,  each  of  which  has  developed  into  an  independent  organ, 
has  been  observed,  as  P.  Mutter  has  shown,  in  adults  as  well  as  in 
infants ;  this  condition  offers  no  obstacle  to  conception,  unless,  in- 
deed, as  occurred  in  a  case  of  Tauffcr's,  the  vagina  is  rudimentary, 
so  that  normal  sexual  intercourse  is  impossible.  Satschoma  reports 
a  case  of  uterus  didelphys  in  which  pregnancy  occurred  simul- 
taneously in  both  uterine  cavities. 

A  careful  distinction  must  be  made  between  the  congenital  con- 
dition known  as  the  infantile  uterus  (i.  e.,  congenital  atrophy)  and 
acquired  atrophy  of  the  uterus,  affecting  the  whole  organ,  or  either 


500 


THE  SEXUAL  LI.FE  OF  WOMAN. 


of  its  segments,  the  body  or  the  cervix;  the  latter  condition  may 
offer  merely  a  transient  and  curable  obstacle  to  conception. 

Acquired  primary  atrophy  of  the  uterus  occurs  in  weakly  girls 
who,  just  before  the  age  at  which  the  uterus  normally  undergoes 
its  transformation  into  the  adult  state,  have  suffered  from  constitu- 
tional disorders,  from  chlorosis  or  anaemia,  or  from  some  other  ex- 
hausting affection.  The  uterus  is  then  small,  limp,  and  flaccid, 
it  is  usually  anteflexed,  with  a  small,  often  insignificant  portio 
vaginalis;  the  anterior  lip  of  this  structure  failing  to  project  from 
the  vaginal  fornix ;  the  vagina  is  usually  short  and  narrow.  This 
form  of  atrophy  of  the  uterus  is  distinguished  from  the  foetal 
and  from  the  infantile  uterus  more  especially  by  the  fact  that  no 
disproportion  exists  between  body  and  cervix,  that  the  muscular 
wall  is  better  developed,  and  that  the  general  configuration  of  the 
uterus  is  rather  that  characteristic  of  the  normal  uterus  of  the  sex- 
ually mature  woman.  Persons  with  primary  atrophy  of  the  uterus, 
are,  moreover,  backwards  in  the  general  development  of  their 
sexual  characters ;  the  breasts  are  small,  the  pubic  hair  is  scanty, 
the  menstrual  flow  is  insufficient  or  entirely  wanting,  whilst  severe 
dysmenorrhoeal  manifestations  are  usual. 


FIG.  70. —  Congenital  Atrophy  .of  the  Uterus  (after 
Virchow).  oi,  Ostium  internum;  oe,  Ostiurn 
Externum, 


FIG.  71. 


In  favourable  circumstances,  when  the  constitution  becomes  more 
powerful,  in  these  cases  of  primary  atrophy  of  the  uterus,  improve- 
ment takes  place;  the  uterus  undergoes  further  development,  men- 
struation becomes  more  abundant,  and  the  woman  may  become 
pregnant.  Such  a  favourable  prognosis  cannot,  however,  be  enter- 
tained if  a  severe  flexion  of  the  uterus  is  associated  with  the  atrophy 
of  the  organ ;  or  if  the  ovaries  are  also  atrophied. 

Sterility  results  also  from  puerperal  atrophy  of  the  uterus.  This 
Condition  is  a  sequel  of  severe  puerperal  diseases,  metritis,  para- 


THE  SEXUAL  EPOCH  OF  THE  MENACME.  501 

tnetritis,  and  perimetritis ;  sometimes,  even  in  the  absence  of  such 
inflammatory  processes,  it  is  due  to  puerperal  hyperinvolution,  oc- 
curring especially  in  women  previously  weak  in  constitution,  and 
manifested  by  the  fact  that,  notwithstanding  the  weaning  of  the 
child,  the  menstrual  flow  remains  for  months  in  abeyance.  The 
uterus  loses  its  firm  consistency;  it  is  sometimes  shortened,  some- 
times of  normal  length,  but  the  walls  are  always  greatly  thinned, 
so  that,  as  Schroeder  points  out,  the  sound  can  be  readily  felt, 
through  the  abdominal  wall.  Puerperal  atrophy  is  a  curable  con- 
dition, so  that  the  sterility  dependent  upon  this  disease  is  not  neces- 
sarily permanent.  Thus,  in  a  case  of  P.  Muller's,  a  woman  in  whom 
a  twin  delivery  had  been  followed  by  extreme  atrophy  of  the  uterus, 
with  well-marked  symptoms  both  objective  and  subjective,  became 
once  more  pregnant  eighteen  months  after  the  termination  of  the 
twin  pregnancy.  • 

Other  forms  of  atrophy  of  the  uterus  have  a  similar  deleterious 
effect  to  that  exercised  by  puerperal  atrophy,  as,  for  instance, 
atrophy  from  the  pressure  of  tumours  of  the  uterus,  or  of  solid 
ovarian  tumours ;  or,  again,  atrophy  due  to  defective  innervation  of 
the  pelvic  organs,  occurring  in  various  forms  of  paralysis,  and 
characterised  by  amenorrhoea  and  extreme  smallness  of  the  uterus. 
Von  Scansoni  has  seen  several  cases  in  which  young  women,  pre- 
viously healthy  and  menstruating  with  regularity,  have  been  attacked 
by  paralysis  of  the  lower  extremities,  and  thenceforwards  have  suf- 
fered from  amenorrhoea  and  great  contraction  of  the  uterus;  in 
some  of  these  cases  a  post  mortem  examination  was  made,  and  dis- 
closed the  existence  of  true  atrophy  of  the  uterus.  Jaquet  saw  a 
similar  case  of  atrophy  of  the  uterus  in  a  lady  who  had  been 
frightened  by  witnessing  the  storming  of  a  barricade  in  front  of  her 
dwelling;  she  was  then  in  her  22nd  year,  and  had  given  birth  to 
her  second  child  il/2  years  previously;  thenceforwards  she  was  com- 
pletely amenorrhoeic,  and  her  uterus  measured  only  3  cm.  (1.2  in.) 
in  length. 

Displacements  of  the  uterus  (flexions  and  versions),  and  abnor- 
malities in  the  cervix  uteri,  are  among  the  conditions  which  lead 
to  sterility  by  interfering  with  conjugation  —  by  preventing  the 
necessary  physical  contact  between  the  male  and  the  female  repro- 
ductive elements.  The  frequency  with  which  these  diseases  give 
rise  to  sterility  is,  however,  far  from  being  so  great  as  is  commonly 
asserted  bv  those  who  maintain  a  mechanical  theory  of  conception. 

Pathological  Changes  in  the  Cervix  Uteri. 

In  very  early  times,  the  attention  .of  physicians  was  directed  to 
abnormalities  in  the  shape  of  the  cervix  uteri,  as  offering  hin- 


COLLIEUIE   01-- 


502  THE  SEXUAL  LIFE  OF  WOMAN. 

drances  to  the  entry  of  the  semen  into  the  uterus.  Amongst  the 
writers  of  antiquity  who  have  alluded  to  this  matter,  the  names  of 
Hippocrates  and  S  or  anus  must  especially  be  mentioned. 

The  normal  cervix  uteri  (Fig.  72)  has  the  form  of  a  flattened 
elipsoid,  perforated  throughout  its  longitudinal  axis.  On  making 
a  longitudinal  section  of  the  cervical  canal,  we  see  that  it  is  dilated 
in  the  middle,  and  tapers  towards  either  extremity,  having  thus 
the  shape  of  a  spindle ;  the  internal  os  is,  however,  somewhat  smaller 
than  the  external.  The  latter  (os  uteri  externum,  os  tincae,  often 
referred  to  without  qualification  as  "the  os"),  has  normally  the 
form  of  a  transverse  fissure,  which,  however,  tends  more  towards 
the  circular  form,  the  smaller  it  is,  and  the  more  widely  its  margins 
are  separated.  In  childhood,  in -consequence  of  the  infolding  of  its 
margins,  the  external  os  has  usually  a  radiated  form,  later  it  be- 
comes rounded,  and  only  with  the  attainment  o£  sexual  maturity 
does  it  assume  the  form  of  a  transverse  slit.  This  form  is  main- 
tained throughout  the  epoch  of  active  sexual  life ;  but  after  the 
climacteric,  owing  to  the  separation  of  the  margins  of  the  orifice,  it 
becomes  once  more  rounded. 

With  regard  to  the  greatly  varying  size  and  shape  of  the  portio 
vaginalis,  it  may  be  said  that  in  general  its  anterior  lip  appears  the 
shorter  of  the  two,  owing  to  the  lesser  depth  of  the  anterior  vaginal 
fornix,  but  that  in  reality  the  anterior  wall  of  the  cervical  canal  is 
longer  than  the  posterior ;  the  actual  length  of  the  anterior  lip  of 
the  portio  vaginalis,  measured  from  the  summit  of  the  anterior 
fornix,  is  from  l/2  to  I  cm.  (0.2  to  0.4  in.),  whilst  the  posterior  lip, 
from  the  summit  of  the  posterior  fornix  to  the  end  of  the  lip  meas- 
ures 1 1/2  cm.  (0.6  in.)  and  upwards.  The  position  of  the  cervix  is 
such  that,  owing  to  the  oblique  direction  of  the  long  axis  of  the 
uterus,  superaclded  to  the  absolutely  greater  length  of  the  anterior 
lip  of  the  cervix,  the  plane  across  the  extremities  of  the  two  lips 
faces  almost  straight  backwards.  The  axis  of  the  portio  vaginalis 
forms  a  right  angle  with  the  axis  of  the  vagina ;  the  cervical  canal, 
however,  is  not  usually  straight,  but  has  a  slight  S-shaped  curva- 
ture. The  mean  length  of  the  cervical  canal  in  the  virgin  uterus 
is  3  cm.  (1.2  in.).  (Lott.) 

The  "  ideal  "  form  of  the  cervix  uteri  and  of  the  os  uteri  ex- 
ternum is  described  by  Sims  in  the  following  terms:  "The  vaginal 
portion  should  measure  about  one  fifth,  certainly  not  more  than  one 
fourth,  of  the  entire  length  of  the  cervix  uteri ;  that  is,  the  anterior 
lip  should  have  a  length  of  one  fourth  to  one  third  of  an  inch,  and 
the  posterior  lip  should  be  a  fraction,  longer.  The  cervical  canal 
should  either  be  straight,  or  have  a  forwardly  directed  curve ;  the 
cervical  axis  should  form  a  right  angle  with  the  vaginal  axis ;  the 
cervix  should  not  be  markedly  anteverted  or  retroverted."  $inis 


THE  SEXUAL  EPOCH  OF  THE  MENACME. 


503 


is  of  opinion  that  every  woman  whose  uterus  is  in  this  condition  will 
conceive  within  three  or  four  months  from  the  time  when  she  first 
enters  upon  conjugal  intercourse;  he  adds,  however,  the  important 
proviso,  "  be  it  understood,  that  all  else  is  in  order." 


FIG.  72. —  Normal    Portio 
Vaginalis. 


FIG.   73. —  Conoidal 
Portio   Vaginalis. 


In  conception,  the  cervix  uteri  subserves  the  important  function 
of  providing  for  the  free  passage  of  the  spermatozoa  to  the  interior 
of  the  uterus;  and  when  we  consider  the  nature  of  the  processes  of 
sexual  intercourse  and  fertilization,  and  more  especially  when  we 
bear  in  mind  that  normally  the  two  lips  of  the  cervix  and  the  upper 
segment  of  the  vagina  form  a  chamber  for  the  retention  of  a  portion 
of  the  seminal  fluid  in  contact  with  the  os  uteri  externum,  we  are 
readily  led  to  assume  that  any  great  abnormality,  in  size  of  the  cervix 
(enlagement  or  diminution),  in  its  shape  (malformation),  or  in  its 
position  (displacements  —  flexion,  version,  or  prolapse),  or,  finally, 
stenosis  of  the  cervical  canal, —  may  offer  mechanical  hindrances  to 
conception.  An  experience  shows  that  this  assumption  is  justified, 
at  any  rate  as  regards  conical  elongation  of  the  portio  vaginalis 
(Fig.  73),  as  regards  an  apron-shaped  or  beak-shaped  hypertrophy 
•of  the  anterior  lip  of  the  cervix  (Figs.  74  and  75),  as  regards 
flexion  upwards  of  the  elongated  cervix,  and  also  as  regards  stenosis 
or  obliteration  of  the  external  or  the  internal  os ;  although  the 
reservation  must  be  made  that  no  matter  how  unfavourable  the 
shape  of  the  portio  vaginalis,  no  matter  how  extensive  the  changes 
in  the  cervix  uteri,  as  long  as  a  permeable  upward  passage  for  the 
spermatozoa  exists,  conception  is  still  possible,  and  in  exceptional 
cases  may  occur. 


504 


THE  SEXUAL  LIFE  OF  WOMAN. 


When  the  cervix  is  hypertrophic  and  greatly  enlarged,  and  the 
vaginal  fornix  consequently  much  elongated,  conception  is  rendered 
difficult,  for  the  reason  that  in  such  cases,  either  the  semen  rapidly 
flows  out  of  the  vagina,  or  else  a  proper  juxtaposition  between  the 
penis  and  the  external  os  no  longer  occurs,  and  the  semen  is  ejacu- 


FIG.  74. — "Apron-shaped" Vaginal    FIG.  75. —  "Beak-shaped"  Vaginal  Por- 
Portion.       a.  Greatly   elongated  tion.     Posterior  aspect, 

anterior  lip ;  b.  Shorter  posterior 
lip  of  the  cervix. 

lated  at  some  distance  from  the  os.  The  change  in  the  shape  of 
the  portio  vaginalis,  and  also  the  elongation  of  the  cervical  canal, 
are  additional  obstacles  to  the  entrance  of  the  spermatozoa  into 
the  interior  of  the  uterus ;  as  regard's  the  former  condition,  in 
nulliparae  the  portio  vaginalis  is  commonly  conical,  or  pointed, 
whilst  the  external  os  is  very  small,  thus  rendering  the  passage  of 
the  spermatozoa  a  difficult  matter ;  but  in  parous  women,  it  is  lobu- 
lated,  owing  to  the  presence  of  deep  fissures,  whereby  the  penis 
is  conducted  into  the  vaginal  fornix,  and  the  ejaculation  of  the 
semen  in  this  locality  is  facilitated.  Hence,  such  hypertrophy  of 
the  cervix  and  the  portio  vaginalis  often  coincides  with  the  occur- 
rence of  sterility.  The  hypertrophy  is  less  apt  to  cause  sterility 
when  it  is  limited  to  one  lip  of  the  cervix,  unless,  indeed,  the  affected 
lip  (more  commonly  the  anterior)  is  so  greatly  enlarged  that  it 
bends  over  and  occludes  the  external  os,  whilst  conducting  the  penis 
into  the  fornix  and  awav  from  the  orifice.  Cases  have  been  known 


THE  SEXUAL  EPOCH  OF  THE  MENACME.  505 

in  which  a  single  lip  of  the  cervix  was  hypertrophied  to  such  an 
extent  as  to  protrude  between  the  labia. 

The  commonest  malformation  of  the  cervix  is  the  conical  cervix, 
when  the  cervix  is  not  merely  elongated,  but  tapering;  associated 
with  this  condition  is  usually  found  a  notable  diminution  in  size 
of  the  os  uteri  externum.  According  to  Sims  we  find  "conical 
cervix  in  85%  of  all  cases  of  natural  sterility."  According  to  the 
same  author,  even  in  the  absence  of  the  conical  form  of  cervix, 
"  sterility  is  probable  in  cases  in  which  the  portio  vaginalis  projects 
fully  half  an  inch  into  the  vagina;  if  the  cervix  projects  more 
than  one  inch,  sterility  almost  inevitably  results ;  whilst  if  elonga- 
tion is  even  greater  than  this,  so  that  the  vaginal  portion  measures 
from  one  and  a  half  to  two  inches,  sterility  is  absolutely  certain." 

On  the  other  hand,  congenital  smallness  of  the  portio  vaginalis, 
the  condition  in  which  this  organ  appears  merely  as  a  slightly  pro- 
jecting nodule  on  the  upper  part  of  the  anterior  wall  of  the  vagina, 
the  anterior  vaginal  fornix  being  almost  non-existent,  and  the 
posterior  fornix  very  extensive — a  wide  cul-de-sac — is  also  un- 
favourable to  conception.  The  probable  reason  is  that,  in  conse- 
quence of  this  deformity,  the  semen,  after  being  ejaculated  into  the 
posterior  fornix,  flows  away  down  the  posterior  wall  of  the  vagina, 
without  coming  into  contact  with  the  short  portio  vaginalis. 

According  to  Beigel,  another  frequent  cause  of  sterility  is  to  be 
found  in  the  existence  of  the  so  called  "  apron-shaped  "  portio 
vaginalis,  the  condition  in  which,  either  from  congenital  deformity, 
or  else  from  hypertrophy  or  some  other  disease,  one  lip  of  the 
vaginal  portion  is  so  formed  as  greatly  to  exceed  the  other  in 
length. 

In  consequence  of  hypertrophy,  the  portio  vaginalis  may  asume 
other,  very  Various  forms ;  in  some  cases  it  may  increase  in  size  to 
such  an  extent  that  it  projects  into  the  vagina  as  a  thick,  hard 
ball,  and  thus  offers  a  serious  obstacle  to  the  reception  of  the  semen ; 
or,  again,  in  the  form  of  the  elongated,  slender  cervix,  it  may 
become  doubled  upon  itself,  and  in  this  way  hinder  the  passage  of 
the  spermatozoa  (Figs.  76  and  77).  Deformities  of  the  cervix  due 
to  hypertrophy  of  the  portio  vaginalis,  rarely  cause  congenital 
sterility,  but  more  commonly  the  acquired  form ;  for  such  hyper- 
trophy is  hardly  ever  congenital,  occurs  but  rarely  in  virgins,  and 
is  usually  met  with  in  married  women  who  have  had  difficult  de- 
liveries, and  consequently  have  suffered  from  uterine  disease. 

Another  deformity  of  the  vaginal  portion  of  the  cervix  which 
is  important  in  its  relations  to  sterility  is  the  "snout-shaped  cervix." 
Here  the  cervix  is  thinnest  immediately  at  its  insertion  into  the 
vaginal  fornix,  and  thickens  gradually  below,  so  that  the  organ 
resembles  a  swine's  snout  in  form.  As  a  rule,  this  deformity  is 


506 


SEXUAL  LIFE  OF  WOMAN. 


due  to  diffuse  hypertrophy  of  the  connective  tissue  of  the  cervix, 
the  result  of  chronic  endometritis  and  cervicitis. 


FIG.  76. —  Simple  Hypertrophy  of 
the  Portio  Vaginalis,  which 
projected  from  the  Vulva. 


FIG.  77.-—  Elongated  Cervix, 
bent  upwards. 


Fritsch,  however,  in  two  cases  of  characteristic  col  tapiroid,  saw 
pregnancy  occur  after  the  relief  of  the  previously  existing  uterine 
catarrh;  in  one  of  these  cases  the  condition  of  the  organs  was 
virginal,  so  that  it  was  hardly  possible  to  believe  that  the  patient 
was  a  multipara ;  even  after  she  had  had  three  children,  the  os 
uteri  externum  with  difficulty  admitted  the  passage  of  the  uterine 
sound. 

Pajot  has  devoted  especial  attention  to  the  hindrances  that  are 
offered  to  the  entrance  of  the  spermatozoa  by  displacements  of  the 
cervix.  In  these  cases,  during  coitus,  the  extremity  of  the  glans 
penis  is  not  in  contact  with  the  os  uteri  externum,  but  passes  into 
a  kind  of  cul-de-sac ;  in  retroversion  the  posterior  fornix ;  in  ante- 
version,  the  anterior  fornix;  in  lateral  version,  the  lateral  fornix  of 
the  side  opposed  to  that  towards  which  the  lower  extremity  of  the 
cervix  points. 

Complete  absence  of  the  vaginal  portion  of  the  cervix  puts  dif- 
ficulties, though  not  very  serious  ones,  in  the  way  of  conception, 


THE  SEXUAL  EPOCH  OF  THE  MENACME.  507 

since  the  segment  of  the  uterus  which  combines  with  the  upper 
segment  of  the  vagina  to  form  a  receptaculum  seminis,  is  wanting. 
How  important  in  predisposing  to  fertilization  is  efficient  contact 
of  the  external  orifice  of  the  vaginal  portion  with  the  ejaculated 
semen  during  and  immediately  after  intercourse,  seems  to  be  estab- 
lished by  my  own  observation,  that  women  of  small  stature  married 
to  men  of  average  height  exhibit  much  higher  proportional  fertility 
than  women  of  average  stature.  In  the  case  of  these  small  women, 
the  favourable  circumstance  is  obvious,  inasmuch  as  intimate  con- 
tact is  facilitated  between  glans  penis  and  portio  vaginalis.  I  have 
frequently  heard  complaints,  from  the  husbands  of  such  women, 
that  a  single  coitus  is  sufficient  to  ensure  conception ;  and  again 
and  again  I  have  been  informed  by  such  women  that  they  have  had 
10,  12,  or  16  children.  In  one  such  instance  known  to  me,  the  wife 
had  been  pregnant  23  times,  and  had  given  birth  to  19  normal  chil- 
dren. Contrariwise,  women  with  a  very  long  vagina,  and  with  a 
high  position  of  the  portio  vaginalis,  do  not  so  easily  become  preg- 
nant. 

Of  special  importance  in  the  causation  of  sterility  is  stenosis  of 
the  cervical  canal.  This  may  be  congenital,  and  then  usually  affects 
the  whole  length  of  the  canal ;  or  it  may  be  acquired,  being  depend- 
ent upon  inflammation  of  the  mucous  membrane.  In  these  latter 
cases,  the  swollen  follicles  of  the  mucous  membrane  burst,  and  their 
granulating  walls  adhere.  Other  causes  of  acquired  stenosis  are 
trauma,  severe  operative  procedures  during  parturition,  puerperal 
inflammations,  syphilitic  ulceration,  adhesion  of  the  opposed  granu- 
lating surfaces  after  operative  measures  (as,  for  instance,  after 
severe  cauterization,  or  after  amputation  of  the  portio  vaginafis), 
and,  in  short,  from  scar-formations  however  caused. 

General  swelling  of  the  tissues  leading  to  stenosis  occurs  at  the 
external  os  in  hyperplastic  uteri  of  virgin  configuration ;  the  small 
round  orifice  characteristic  of  the  virgin  uterus  becomes  narrowed, 
or  even  completely  occluded,  by  the  swelling  of  the  tissues  of  the 
vaginal  portion.  True  adhesion  of  the  walls  does  not  occur  in 
these  cases,  but  the  minute  aperture  left  by  the  swelling  of  the 
walls  of  the  canal  is  plugged  by  the  epithelium,  so  that  a  small 
blind  depression  in  the  centre  of  the  portio  vaginalis  is  all  that 
remains  of  the  cervical  canal.  Such  a  condition  is  seen  with  especial 
frequency  in  cases  of  prolapse  of  the  vaginal  portion,  and  is  often 
erroneously  regarded  as  an  obliteration  of  the  os  uteri  externum 
by  epithelial  adhesion  (Klcbs}.  Finally,  stenosis  of  the  cervical 
canal  may  be  caused  by  tumours,  and-  also  by  the  flexions  and 
versions  of  the  uterus  presently  to  be  discussed. 

Congenital  atresia  of  the  uterus  is  generally  associated  with  other 
developmental  anomalies  of  the  reproductive  organs.  In  some  cases, 


508  THE  SEXUAL  LIFE.  OF  WOMAN. 

all  that  is  at  fault  is  that  the  mucous  covering  of  the  vaginal  portion 
passes  uninterruptedly  from  one  lip  to  the  other;  but  in  others,  the 
cervix  is  unperforated  throughout,  and  the  vaginal  portion  is  but 
slightly  developed. 

Acquired  obliteration  of  the  cervical  canal  may  affect  either  the 
external  or  the  internal  os,  with  a  shorter  or  longer  portion  of  the 
rest  of  the  canal.  When  very  extensive  necrosis  of  tissue  has 
occurred,  as  a  sequel  of  difficult  delivery,  the  adhesion  may  include 
the  adjoining  segment  of  the  vagina  (uterovaginal  atresia). 

The  more  marked  the  stenosis  of  the  cervical  canal,  the  smaller  the 
passage  by  which  the  vagina  communicates  with  the  uterus,  the  more 
difficult  will  it  be  for  the  passage  of  the  spermatozoa  to  be  effected, 
so  that  of  the  millions  of  spermatozoa  deposited  in  the  neighbour- 
hood of  the  os  uteri,  thousands  will,  as  in  normal  cases,  find  their 
way  to  the  uterine  orifices  of  the  Fallopian  tubes.  So  much  the  more, 
then,  is  the  contact  between  spermatozoon  and  ovum  rendered  difficult, 
and  so  much  the  more  unlikely  is  it  that  conception  will  occur.  More- 
over, in  consequence  of  the  stenosis,  there  is  retention  of  the  cervical 
mucus,  which  becomes  thick  and  glutinous,  and  offers  a  further 
obstacle  to  the  passage  of  the  spermatozoa.  The  unfavourable  in- 
fluence upon  the  possibility  -of  conception  is,  finally,  increased  if, 
as  is  often  the  case,  in  association  with  the  stenosis,  the  cervix 
becomes  elongated  and  assumes  a  conical  form  (these  secondary 
changes  probably  resulting  from  the  inflammatory  states  of  the 
cervix  common  in  cases  of  stenosis)  ;  and  an  additional  obstacle  is 
offered  to  conception  by  the  association  with  the  stenosis  of  flexion 
or  version  of  the  uterus.  It  is  in  such  complicated  cases  that  we  so 
often  have  the  associated  symptoms  of  dysmenorrhoea  and  sterility ; 
the  dysmenorrhoea  being  due  to  the  fact  that  the  menstrual  dis- 
charge, if  abundant,  is  unable  to  flow  way  with  sufficient  rapidity 
through  the  greatly  narrowed  cervical  canal ;  exuding  from  the 
vessels  of  the  uterine  mucous  membrane  more  rapidly  than  it  can 
be  discharged,  it  accumulates  in  the  uterine  cavity,  and  gives  rise 
to  painful  contractions  of  the  uterus. 

Precisely  what  degree  of  narrowing  of  the  cervical  canal  it  is 
which  constitutes  pathological  stenosis,  is  in  practice  by  no  means 
easy  to  define;  and  only  in  regard  to  extreme  cases  of  pathological 
constriction  can  there  be  no  possibility  of  dispute.  In  cases  of 
congenital  stenosis  of  the  cervical  canal,  the  diagnosis  is  very 
easy,  for  the  os  uteri  externum  is  then  always  extremely  small; 
often  the  aperture  is  no  larger  than  a  small  pin's  head,  a  very 
fine  probe  can  be  passed  through  it  with  considerable  difficulty 
and  its  passage  is  opposed  all  the  way  up  to  the  internal  os. 
But  in  cases  of  acquired  stenosis  of  moderate  severity,  the 
diagnosis  is  often  difficult.  Owing  to  the  small  size  of  the 


THE  SEXUAL  EPOCH  OF  THE  MENACME.  509 

orifice,  and  to  the  extensibility  of  the  soft  parts  by  which  it  is 
surrounded,  exact  measurements  are  impossible.  When  the  os  is 
with  difficulty  detected  by  the  skilled  finger,  when  the  sound  is  not 
readily  introduced  by  the  experienced  hand,  slipping  past  again  and 
again,  and  inserted  only  after  repeated  efforts — such  an  os  is,  as 
Olshausen  insists,  always  pathological.  The  normal  virgin  os  uteri 
permits  the  easy  passage  of  a  thick  uterine  sound  with  a  diameter 
of  3  to  4  millimeters  ( J  to  £  in.)  ;  but  there  are  cases  in  which, 
though  a  sound  of  this  normal  size  can  be  passed,  the  os  gives  to  the 
examining  finger  the  sensation  of  being  contracted.  If,  in  such  a 
case  there  is  typical  mechanical  dysmenorrhoea  with  sterility,  Ols- 
hauscn  considers  that  we  are  justified  in  assuming  the  existence  of 
pathological  stenosis  of  the  os  uteri,  and  in  treating  the  case  ac- 
cordingly. 

However,  as  Kehrer  insists,  it  may  be  one  of  the  greatest  dif- 
ficulties in  diagnosis — a  difficulty  not  always  to  be  resolved  even 
when  all  the  attendant  circumstances  have  received  the  fullest  and 
most  painstaking  consideration — to  determine  whether  in  any  in- 
dividual  case  an  anomaly  of  the  cervix,  such  as  stenosis  of  the 
external  os  or  of  the  whole  cervical  canal,  is  or  is  not  to  be  regarded 
as  a  cause  of  sterility.  When  stenosis  is  extreme,  there  need  be  no 
two  opinions  about  the  matter ;  the  difficulty  is  in  cases  lying 
somewhere  between  a  moderate  degree  of  contraction  and  the  lower 
physiological  limit  of  smallness.  Every  experienced  gynecologist 
will  have  -seen  such  cases  as  Kehrer  describes,  in  which  before 
marriage  the  os  appeared  extremely  small,  and  yet  soon  after  mar- 
riage the  woman  became  pregnant.  For  this  reason  we  are  justified, 
with  O.  Johannscn,  in  reverting  rather  to  the  functional  than  to  the 
anatomical  conception  of  stenosis,  and  in  maintaining  that  so  long 
as  the  cervical  canal  is  sufficiently  large  to  permit  the  uterine  secre- 
tions to  flow  freely  away,  any  stenosis  that  may  exist  is  devoid  of 
pathological  significance.  Only  when  the  outlet  for  the  uterine  se- 
cretions is  insufficient,  so  that  the  uterine  cavity  becomes  distended 
(as  manifested  by  an  elongation  of  the  canal  in  the  supra  vaginal 
portion  of  the  uterus,  and  by  various  disorders,  amongst  others 
chronic  endometritis),  is  the  stenosis  with  its  consecutive  dilatation 
of  the  uterus  a  serious  obstacle  to  conception.  "  In  such  cases,  the 
contractions  of  the  uterus  during  coitus  will  not  suffice  to  express 
the  secretions  it  contains  through  the  narowed  os,  and  the  inevitable 
consequence  of  the  incomplete  evacuation  of  the  uterus  is  that  the 
aspiratory  phase  of  the  orgasm  fails  to  occur." 

According  to  W'mckel,  stenosis  of  the  external  or  of  the  internal 
os  is  a  cause  of  sterility  only  in  cases  in  which  it  arises  from  a 
follicular  inflammation  of  the  cervical  mucous  membrane ;  in  such 
cases,  the  os,  (internal  or  external,  as  the  case  may  be),  being 


5*0 


THE  SEXUAL  LIFE  OF  WOMAN. 


greatly  narrowed  by  the  numerous  retention  cysts,  offers  an  obstruc- 
tion to  the  evacuation  of  the  glutinous  secretion  of  the  follicles 
yet  remaining  open.  This  secretion  may  offer  an  insuperable  hin- 
drance to  the  passage  of  the  spermatozoa;  but  in  the  absence  of 
catarrh  of  this  character,  a  moderate  degree  of  contraction  of  the 
cervical  canal  will  not  prevent  the  outflow  of  the  menstrual  dis- 
charge, or  the  upward  passage  of  the  spermatozoa. 

The  experience  of  horse  and  cattle  breeders  also  shows  the 
etiological  importance  of  stenosis  of  the  cervix  in  the  production 
of  sterility ;  and  in  the  case  of  mares  and  cows  who  are  unfruitful 
from  this  cause,  artificial  dilatation  of  the  cervix  has  often  been 
performed,  with  resulting  restoration  of  fertility. 

Swelling  of  the  follicles  of  the  mueous  membrane  of  the  cervical 
canal  or  of  the  cavity  of  the  uterus,  a  condition  which  often  results 
from  cervical  catarrh,  will,  equally  with  stenosis  of  the  cervical 
canal,  lead  to  sterility ;  pushing  the  mucous  membrane  before  them, 
and  becoming  pedunculated,  these  swollen  follicles  ultimately  enlarge 
to  form  polypi  of  the  cervical  canal  or  the  uterine  cavity,  and  may  at 
times  completely  occlude  the  uterine  canal.  In  Fig.  78  is  depicted  a 
polypus  of  this  kind,  which  I  removed  from  the  cervix  of  a  barren 
woman  30  years  of  age.  On  the  apex  of  the  polypus  was  a  large 
ovulum  Nabothi. 


FIG.   78. —  Cervical   Polypus,  originating  from  an  Ovulum   Nabothi. 


Long-standing  cervical  catarrh  readily  leads  to  stenosis  of  the 
cervical  canal,  and  consequently  to  sterility.  The  swelling  and 
hypersecretion  of  the  cervical  mucous  membrane  the  more  readily 
hinders  the  entrance  of  the  semen,  inasmuch  as  the  mucous  folds  on 
the  anterior  and  posterior  walls  of  the  cervical  canal  which  combine 
to  form  the  plicae  palmatae  are  in  the  normal  state  already  sufficiently 
prominent ;  but  in  cases  of  catarrhal  swelling  they  may  project  to 
such  an  extent  as  completely  to  occlude  the  canal.  Stagnation  of 
the  thickened  secretion  offers  in  these  cases  a  further  hindrance 


THE  SEXUAL  EPOCH  OF  THE  MENACME.  511 

to  the  passage  of  the  spermatozoa,  a  stagnation  which  becomes 
aggravated  if  in  course  of  time  the  os  becomes  stenosed  by  over- 
growth of  scar  tissue.  Ultimately,  also,  in  cases  of  chronic  catarrh, 
a  flexion  of  the  enlarged  and  flabby  corpus  uteri  readily  occurs,  and 
this  imposes  an  additional  difficulty  in  the  way  of  conception. 

It  is  for  these  reasons  that  those  women  who  in  girlhood  have 
suffered  from  prolonged  cervical  catarrh,  so  often  remain  childless. 
The  sequence  of  events  is  that  already  described :  follicular  catarrh, 
stagnation  of  secretions,  stenosis  of  the  cervical  canal,  enlargement 
and  loss  of  tone  of  the  uterus ;  the  thin-walled,  enlarged,  and  flaccid 
uterus  ultimately  gives  way  before  the  intra-abdominal  pressure, 
bending  back,  usually,  into  the  pouch  of  Douglas.  Thus,  retroflex- 
ion  of  the  uterus  is  a  common  sequel  of  cervical  catarrh  (Hilde- 
brandt).  In  some  cases  of  sterility  dependent  upon  cervical  catarrh, 
this  sequence  of  troubles  has  not  occurred,  and  it  is  merely  the 
mucus  in  the  canal  which  prevents  the  passage  of  the  spermatozoa. 
B.  Schultze  reports  the  case  of  a  woman  who  had  lived  for  13 
years  in  sterile  wedlock,  but  became  pregnant  after  a  single  removal 
of  the  cervical  mucus. 

The  significance  of  chronic  cervical  catarrh  in  the  causation  of 
sterility  explains  how  it  is  that  in  many  cases  of  barren  marriage 
the  blame  ultimately  rests  upon  the  husband,  who,  when  he  married, 
was  suffering  from  "  latent  gonorrhoea,"  the  inconspicuous  relic  of 
an  acute  attack,  undergone,  it  may  be,  months  and  even  years 
previously,  and  infected  his  wife  with  the  disease.  Such  a  gon- 
orrhoeal  catarrh  is  in  women  especially  apt  to  assume  a  chronic 
form,  and  will  then  induce  all  the  secondary  morbid  conditions 
previously  described,  and  thus  lead  to  sterility. 

Gonorrhoea  in  women  frequently  results  in  sterility.  In  addition 
to  the  effect  of  cervical  stenosis  and  of  a  morbid  condition  of  the 
cervical  mucus  in  preventing  the  upward  passage  of  the  sperma- 
tozoa, this  disease  may  lead  to  many  other  changes  inimical  to 
fertility.  Thus,  gonorrhoeal  infection  in  women  often  leads  to 
inflammatory  manifestations  in  the  peritoneum,  the  perimetrium,  and 
the  parametrium,  and  to  catarrhal  changes  in  the  Fallopian  tubes 
(salpingitis,  hydrosalpinx,  pyosalpinx)  ;  these  prevent  the  contact 
of  spermatozoon  and  ovum,  or  cause  pathological  distortions  of  the 
walls  or  calibre  of  the  tubes,  which  constitute  permanent  hindrances 
to  the  occurrence  of  conception.  Young  married  women,  whose 
husbands  at  the  time  of  marriage  were  the  subjects  of  incompletely 
cured  gonorrhoea,  and  v^o  shortly  after  marriage  suffer  from 
cervical  catarrh,  the  discharge  from  the  inflamed  mucous  membrane 
not  infrequently  having  a  suspicious  greenish  colour  analogous  to 
that  seen  in  recent  gonorrhoea  in  the  male,  often  remain  sterile  for 
long  periods,  owing  to  this  gonorrhoeal  cervical  catarrh,  endome- 


512  THE  SEXUAL  LIFE  OF  WOMAN. 

tritis,  and  tubal  catarrh.  For  the  diagnosis  in  such  cases,  in  addition 
to  noticing  the  virulent  character  of  the  inflammation  of  the  vulva, 
urethra,  and  vagina,  we  must  invoke  the  aid  of  the  microscope ;  and 
it  will  often  be  possible  to  decide  at  once  that  the  inflammation  is 
gonorrhoeal  by  finding  Neisser's  diplococci  enclosed  within  the  pus 
cells  of  the  cervical  secretion. 

The  influence  of  "  latent  gonorrhoea  "  in  diminishing  the  fertility 
of  women  has  been  especially  asserted — and  overestimated — by 
Nogycrath.  From  the  fact  that  about  90$  of  sterile  women  are 
married  to  men  who  have  suffered  from  gonorrhoea  either  before 
or  during  their  married  life,  he  infers  that  the  sterility  is  due  to 
latent  gonorrhoea  communicated  from  husband  to  wife.  If  this 
inference  were  justified,  sterility  would  be  far  commoner  than  it 
actually  is.  Noggerath  makes  use  of  the  term  "  latent  gonorrhoea  " 
because  the  woman  becomes  infected  without  the  obvious  outbreak 
of  any  acute  phase  of  the  disorder.  The  disease  remains  latent, 
and  a  radical  cure  is  not  to  be  expected  until  the  menopause.  Ac- 
cording to  Noggerath,  there  are  four  varieties  of  this  disease: 
acute,  recurrent,  and  chronic  perimetritis,  and  oophoritis,  always 
accompanied  by  catarrh  of  the  mucous  membrane  of  the  genital 
organs. 

Sacngcr,  also,  has  asserted  that  12^  of  all  cases  needing  gyneco- 
logical treatment  are  of  gonorrhoeal  origin ;  and  he  even  considers 
that  the  consequences  of  gonorrhoea  are  in  women  more  dangerous 
and  destructive  than  those  of  syphilis.  E.  Martin  has  also  main- 
tained that  endocervicitis  leading  to  stenosis  of  the  os  uteri  exter- 
num  and  of  the  cervical  canal  is,  in  the  majority  of  sterile  young 
wives,  due  to  gonorrhoeal  infection  derived  from  a  chronic,  un- 
healed,  but  inconspicuous,  gonorrhoea  in  the  husband.  He  further 
considers  it  possible  that  various  kinds  of  mechanical  stimulation, 
for  example,  intra-vaginal  onanism,  may,  in  certain  conditions,  give 
rise  to  inflammation  eventuating  in  cervical  stenosis. 

Of  great  interest  are  the  mutual  relations  between  dysmenorrhoea 
and  sterility,  a  matter  to  which  some  allusion  has  already  been 
made.  A  high  degree  of  stenosis  of  the  cervical  canal  is  competent 
to  produce  both  these  symptoms ;  but  dysmenorrhoea  may  arise  from 
many  other  causes  which  have  no  direct  influence  in  preventing  con- 
ception. 

Too  much  stress  has,  in  fact,  been  laid  upon  the  association  of 
dysmenorrhoea  with  sterility,  and  I  must  therefore  point  out  that 
I  have  seen  numerous  instances  of  dysmenorrhoea,  including  the  so- 
called  spasmodic  form  of  the  disease,  in  women  who  have  given 
birth  to  many  children;  that  objectively,  in  such  cases,  there 
was  an  absence  of  that  rigidity  of  the  cervix  to  which 


THE  SEXUAL  EPOCH  OF  THE  MENACME.  513 

Duncan  attached  so  much  importance;  and,  finally,  that  even  when 
the  dysmenorrhoeal  pains  had  subjectively  all  the  character  of  labour 
.pains,  the  introduction  of  the  sound  could  be  effected  without  using 
any  great  force,  and  without  giving  rise  to  any  severe  pain. 

Unquestionably,  those  authors,  with  Sims  at  their  head,  go  too 
far,  who  regard  dysmenorrhoea  as  a  constant  sign  of  stenosis  of  the 
cervical  canal,  and  hence  infer  that  in  all  cases  in  which  sterility  is 
associated  with  dysmenorrhoea,  the  sterility  is  due  to  such  stenosis  — 
an  opinion  contested  by  Schultzc  on  the  ground  of  anatomical  inves- 
tigations. Dysmenorrhoea  gives  no  indisputable  sign  that  the  cervix 
is  stenosed  to  such  a  degree  as  to  hinder  the  occurrence  of  concep- 
tion ;  and  Situs's  view,  that  in  the  great  majority  of  cases  dysmenor- 
rhoea is  due  to  mechanical  obstruction,  is  not  supported  by  experi- 
ence. Women  who  suffer  from  severe  dysmenorrhoea,  frequently 
become  pregnant,  though  later,  it  may  be,  than  women  in  whom 
menstruation  is  normal  and  painless.  Dysmenorrhoea  is  not  due 
solely  to  contraction  of  the  cervical  canal,  but  also  to  a  variety  of 
other  pathological  conditions.  The  anomalies  of  the  genital  organs 
which  give  rise  to  dysmenorrhoea  do  not,  for  the  most  part,  offer 
any  obstacle  to  conception ;  and,  on  the  other  hand,  stenosis  of  the 
cervical  canal  may  exist  in  women  who  are  entirely  free  from  dys- 
menorrhoea. 

In  order  to  test  Sims's  theory  of  the  mutual  interdependence  of 
dysmenorrhoea  and  sterility,  Kchrcr  conducted  an  investigation  into 
the  state  of  menstruation  both  before  and  after  marriage  in  relation 
to  the  fertility  or  infertility  of  the  marriage.  He  ascertained  that  in 
sterile  women  virginal  dysmenorrhoea  had  only  been  a  very  little 
commoner  than  in  fruitful  women.  Hence,  the  changes  in  the  re- 
productive organs  upon  which  the  occurrence  of  dysmenorrhoea 
depends,  must  not  be  regarded  as  necessarily  constituting  hindrances 
also  to  conception. 

English  gynecologists  differ  from  those  of  Germany  is  believing 
that  there  is  an  intimate  causal  relation  between  dysmenorrhoea,  and 
more  especially  spasmodic  dysmenorrhoea,  and  sterility.  The  as- 
sumption is,  that  the  contractions  of  the  uterus,  which  by  their  vio- 
lence during  menstruation  give  rise  to  pains  like  those  of  labour, 
occur  also  during  coitus ;  by  these  contractions,  the  entry  of  the 
semen  into  the  uterus  is  prevented,  or,  if  the  semen  does  enter  the 
uterus,  it  is  speedily  expelled.  This  spasmodic  dysmenorrhoea  has 
also  been  called  mechanical  or  obstructive  dysmenorrhoea,  in  order 
to  call  attention  to  the  theory  that  the  aim  of  the  cramp-like  con- 
tractions of  the  uterus  is  the  expulsion  of  the  menstrual  blood  which 
has  accumulated  in  the  uterine  cavity;  although  Duncan  himself  is 
compelled  to  admit  that  neither  the  alleged  mechanical  obstruction, 
33 


THE  SEXUAL  LIFE  OF  WOMAN. 

nor  the  accumulation  of  menstrual  blood,  nor  yet  the  dilatation  of 
the  uterine  cavity,  can  actually  be  proved  to  occur. 

NOTE. — The  author  is  not  quite  correct  in  his  contrast  between  "  English  " 
and  "  German "  opinion  in  this  matter.  Most  English  gynecologists  follow 
Matthews  Duncan  in  calling  attention  to  the  fact  that,  as  Herman  puts  it, 
"  spasmodic  dysmenorrhoea  is  often  associated  with  sterility " ;  but  almost 
all  careful  writers  insist  that  while  the  association  is  proved,  the  nature  of 
the  causal  connexion,  if  such  exists,  has  not  been  elucidated.  For  instance, 
writing  on  this  very  question  of  the  association  of  dysmenorrhoea  with 
sterility,  JHart  and  Barbour  remark,  "  after  a  careful  survey  of  the  literature, 
we  come  to  the  conclusion  that  any  discussion  of  sterility  in  which  mechanical 
considerations  have  a  prominent  place,  must  be  inadequate,  and  will  always 
be  bootless."  It  is  true  that  Matthews  Duncan  writes  (Diseases  of  Women, 
Lecture  on  Sterility),  "The  most  generally  recognized  cause  of  sterility  is 
spasmodic  dysmenorrhoea " ;  but  a  careful  perusal  of  the  whole  lecture  will 
show  that  Duncan  is  saying  more  than  he  really  means  in  using  the  word 
"  cause,"  and  that  what  he  wishes  to  insist  upon  is  the  frequent  and  indisput- 
able association  of  the  two  conditions.  In  the  lecture  on  Spasmodic 
Dysimnorrhoca  he  writes,  "  Latterly  it  has  been  generally  described  as 
obstructive  or  mechanical  dysmenorrhoea;  these  words  'obstructive'  and 
'  mechanical '  implying  a  theory  of  the  disease  which  ...  I  am  sure  is 
quite  erroneous.'  Obviously,  then,  Kisch  does  injustice  to  Matthews  Duncan 
when  he  writes  that  the  latter  is  "compelled  to  admit"  (obgleich  Duncan 
selbst  zugeben  muss),  what  he  was  as  a  fact  one  of  the  first  to  maintain, 
in  the  face  of  considerable  opposition ! — Transl. 

Duncan  goes  so  far  as  to  maintain  that  no  actual  or  suspected 
local  disturbance  has  such  significance  in  connexion  with  the  doc- 
trine of  sterility  as  spasmodic  dysmenorrhoea.  It  possesses  this  sig- 
nificance owing  to  the  probable  connexion  between  the  dysmenor- 
rhoeic  neurosis  and  the  outflow  of  the  semen,  the  deficiency  of  the 
sexual  impulse  and  of  sexual  pleasure,  and  other  disturbances  of 
sexual  excitement  during  coitus.  With  the  relief  of  the  dysmenor- 
rhoea, we  have,  Duncan  holds,  made  a  long  stride  towards  the  cure 


FIG.  79. —  Ectropium  in  a  Case  of  Bilateral  Laceration  of  the  Cervix.     After 

A.   Martin. 

of  the  sterility.  Among  332  married  women  who  were  absolutely 
sterile.  Duncan  found  159,  nearly  half  of  the  total  number,  who  were 
affected  with  spasmodic  dysmenorrhoea. 


THE  SEXUAL  EPOCH  OF  THE  MENACME.  515 

Burton,  in  order  to  ascertain  with  certain  beyond  question 
whether  stenosis  of  the  external  or  internal  os  gives  rise  to  dysmenor- 
rhoeic  troubles,  examined  six  women  during  menstruation  and  at 
the  time  when  they  were  experiencing  the  greatest  pain ;  he  found  in 
no  one  of  them  any  trace  of  narrowing  of  the  canal.  Owing  to  the 
congestion  that  occurs  at  this  time,  the  uterus  becomes  erect,  and 
any  moderate  flexion  that  may  exist  is  temporarily  straightened.  In 
all  the  cases,  the  sound  could  be  passed  with  extreme  ease. 

Ectropium  of  the  lips  of  the  cervix  ("  granular  erosion")  consti- 
tutes a  hindrance  to  conception  which  is  by  no  means  rare ;  the  con- 
dition is  due  to  deep  lateral  lacerations  of  the  cervix.  The  gaping 
of  the  cervical  canal  arising  from  such  old-standing,  often  over- 
looked, cervical  lacerations  and  from  the  parametric  scars  associated 
therewith,  causes  various  irritative  manifestations:  blenorrhoea, 
blenorrhagia,  cystic  degeneration  of  the  mucous  membrane,  and 
these  secondary  conditions  may  be  contributory  causes  of  sterility; 
but  lacerations  of  the  cervix  with  ectropium  interfere  in  a  manner 
purely  mechanical  with  the  proper  constitution  of  a  receptaculum 
seminis  and  with  the  aspiration  of  the  semen  into  the  cervical  canal. 
(Fig.  79.)  In  an  earlier  section  of  this  work  I  laid  stress  on  the 
fact  that  in  the  act  of  conception  the  musculature  of  the  cervix  had 
in  a  sense  an  active  part  to  play ;  and  the  proper  performance  of  this 
role  is  prevented  by  cervical  lacerations.  The  cervical  glands  also 
suffer  in  cases  of  ectropium,  and  their  function  in  facilitating  the 
entrance  of  the  spermatozoa  into  the  uterine  cavity  is  no  longer 
properly  performed.  Finally,  it  is  worthy  of  note  that  sexual  grati- 
fication, the  sensation  of  voluptuous  pleasure  during  the  sexual  act, 
seems  to  be  diminished  in  women  with  cervical  lacerations,  a  fact 
noted  especially  by  Munde  and  ///.  The  last-named  found  that  in 
34  women  thus  affected,  sexual  gratification  was  no  longer  experi- 
enced in  intercourse ;  whilst  in  27  of  these  cases,  restoration  of  the 
integrity  of  the  cervix  by  operation  was  followed  by  return  of  nor- 
mal sexual  feeling.  In  women  who  have  given  birth  to  one  or  two 
children,  and  then  for  a  long  time  have  remained  barren,  we  not  in- 
frequently find  deep  cervical  lacerations.  Breisky,  Spiegelberg, 
Schultze,  and  Goodell  have  operated  in  such  cases,  and  shortly  after 
the  operation  pregnancy  has  recurred. 

Displacements  of  the  Uterus. 

With  less  justice  than  in  the  case  of  the  pathological  changes  in 
the  cervix  above  described,  it  is  maintained  that  displacements  of 
the  uterus  form  a  very  frequent  cause  of  mechanical  hindrances  to 
conception,  and  thus  give  rise  to  sterility. 

It  certainly  cannot  be  denied  that  displacements  of  the  uterus  are 
found  very  commonly  in  sterile  women ;  and,  on  the  other  hand, 


516  THE  SEXUAL  LIFE  OF  WOMAN. 

among  women  with  pathological  flexion  of  the  uterus,  the  percent- 
age of  the  sterile  is  far  higher  than  among  women  with  a  uterus 
normal  in  position  and  shape  —  but  from  these  facts  it  would  be 
erroneous  to  infer  the  general  conclusion  that  displacements  of  the 
uterus  offer  a  mechanical  hindrance  to  conception.  The  casual  con- 
nexion is  less  simple  than  this  as  a  rule.  In  most  cases  in  which 
displacements  of  the  uterus  are  associated  with  sterility,  there  are 
additional  pathological  states  of  the  uterus  and  its  environment, 
relics  of  previous  inflammation  in  the  uterus,  the  uterine  annexa,  or 
the  parameterium,  or  displacements  of  the  uterine  annexa;  these 
changes  may  be  either  the  cause  or  the  result  of  the  existing  dis- 
placement of  the  uterus,  and  it  is  upon  them,  and  not  primarily 
upon  the  displacement,  that  the  sterility  depends.  The  accuracy  of 
this  view  is  proved  by  the  experience,  by  no  means  an  uncommon 
one,  that  in  such  cases,  when  the  actual  cause  of  the  sterility  is  re- 
moved, the  woman  will  become  pregnant,  although  the  displacement 
of  the  uterus  persists. 

How  difficult  it  is,  in  a  particular  case,  to  determine  whether  the 
pathological  anteflexion  is  the  true  obstacle  to  conception,  or  the 
antecedent  parametritis  posterior  and  the  concomitant  metritis  and 
endometritis !  How  can  we  decide  whether  a  retroflexion  is  the 
simple  mechanical  cause  of  sterility,  or  whether  the  latter  condition 
does  not  rather  depend  upon  complicating  perimetritis  and  oopho- 
ritis  ? 

On  the  other  hand,  we  must  not  fly  to  the  other  extreme,  and 
absolutely  deny  that  a  displacement  of  the  uterus  can  be  the  mechan- 
ical cause  of  sterility.  We  meet  with  cases  in  which  we  are  forced 
to  assume  that  the  flexion  interferes  both  with  the  outflow  of  the 
menstrual  blood  and  with  the  ingress  of  the  seminal  fluid.  And 
this  is  true,  not  merely  of  flexion  to  an  acute  angle,  often  associated 
with  infantile  dimensions  of  the  cervical  canal  or  of  the  external  or 
internal  os,  but  also  of  those  advanced  degrees  of  flexion  in  which, 
doubtless  in  part  also  from  the  accompanying  catarrh,  complete  ste- 
nosis of  the  os  uteri  externum  has  resulted.  The  combination  of 
displacement  of  the  uterus  with  stenosis  of  the  cervix,  is  in  these 
cases  the  essential  hindrance  to  conception.  When  the  os  is  reason- 
ably large,  a  moderate  flexion  of  the  uterus  forwards,  backwards,  or 
to  one  side  or  the  other,  will  not  often  prevent  conception,  for  the 
action  of  the  muscular  bands  in  the  various  ligaments  of  the  uterus 
will  retain  the  os  in  a  sufficiently  favourable  position.  But  if  a  con- 
tracted os  is  associated  with  flexion,  sterility  is  very  likely ;  and 
almost  inevitable,  if  fixation  of  the  flexed  uterus  has  occurred  from 
inflammatory  exudation  and  fibrosis  in  one  of  the  broad  ligaments. 

That  the  belief  that  displacements  of  the  uterus  constitute  an 
obstacle  to  conception  is  a  widely  diffused  one,  is  shown  by  the  fact 


THE  SEXUAL  EPOCH  OF  THE  MENACME.  517 

that  among  certain  nations  a  means  employed  for  the  prevention  of 
pregnancy  is  the  artificial  production  of  displacements  of  the  uterus. 

Of  the  displacements  of  the  uterus,  the  versions,  anteversion,  re- 
troversion,  and  lateral  version,  have  a  more  pronounced  influence  in 
hindering  conception  than  the  flexions ;  for,  in  the  case  of  version  of 
the  uterus,  the  uterus  moves  as  a  whole  round  a  horizontal  axis,  so 
that  when  the  fundus  moves  in  one  direction,  the  portio  vaginalis 
moves  in  the  opposite.  When  the  neck  of  the  uterus  is  thus  dis- 
placed, the  tip  of  the  glans  penis  fails  during  coitus  to  come  into 
contact  with  the  os  uteri  externum,  as  it  normally  should  do,  and 
passes  into  a  vaginal  cul-de-sac,  in  retroversion,  the  posterior  fornix, 
in  anteversion,  the  anterior  fornix,  and  in  lateral  version  the  lateral 
fornix  of  the  side  opposite  to  that  towards  which  the  cervix  uteri  is 
directed.  In  high  degrees  of  this  malposition,  the  vaginal  fornix 
covers  up  the  os  externum  as  with  a  valve.  (Bcigcl.) 

yon  Scanzoni  has  especially  insisted  upon  the  frequency  with 
which  sterility  results  from  chronic  metritis  complicated  with  ante- 
version.  In  59  sterile  women  affected  with  chronic  metritis,  he 
found  in  34  instances  more  or  less  pronounced  anteversion,  and 
hence  was  led  to  infer  that  this  particular  combination  of  disorders 
plays  a  great  part  in  the  production  of  sterility. 

Especially  frequent  is  sterility  in  cases  of  anteversion  of  the  uterus, 
if  in  addition  there  is  some  contraction,  even  though  moderate  in 
degree,  of  the  os  uteri  externum ;  this  combination  of  disorders  is 
one  extremely  unfavourable  to  the  entrance  of  the  spermatozoa  into 
the  uterus. 

Flexion  of  the  uterus  offers  less  hindrance  than  version  to  the 
entrance  of  the  spermatozoa,  for  the  reason  that  in  the  former  con- 
dition the  relations  between  the  vaginal  portion  and  the  glans  penis 
during  coitus  are  not  affected.  But  when  the  flexion  is  extreme  in 
degree,  the  cervical  or  uterine  canal  may  at  some  point  become  abso- 
lutely impassable  for  the  spermatozoa ;  and  further,  extreme  flexion 
is  apt  to  lead  to  the  occurrence  of  parametritis  and  perimetritis. 
But,  generally  speaking,  flexions  of  the  uterus  are  far  less  often  the 
cause  of  sterility,  than  was  formerly  supposed.  It  used  to  be  be- 
lieved that  flexion  of  the  uterus  was  followed  by  stenosis  of  the  os 
uteri  externum,  by  which  the  outflow  of  the  menstrual  blood  and  the 
ingress  of  the  semen  were  equally  prevented.  It  is  true  that  infantile 
acute-angled  flexion  of  the  uterus  is  often  associated  with  infantile 
stenosis  of  the  cervical  canal  or  of  the  internal  or  external  os;  and 
it  is  also  true  that  extreme  degrees  of  flexion  associated  with  uterine 
catarrh,  favour  the  occurrence  of  stenosis  and  obliteration  of  the 
external  os ;  but  B.  Schultze  rightly  insists  that  in  most  of  the  cases 
in  which  a  diagnosis  is  made  of  stenosis  of  the  uterine  canal  associ- 
ated with  a  flexion  of  the  sexually  mature  uterus,  the  supposed 


THE  SEXUAL  LIFE  OF  WOMAN. 


"  stenosis  "  merely  represents  the  difficulty  which  has  been  experi- 
enced in  passing  the  customary  rigid  uterine  sound  past  the  angle  in 
the  uterine  canal.  Still,  the  fact  remains,  that  among  women  with 
uterine  flexion  there  is  a  larger  percentage  of  sterile  individuals  than 
among  women  whose  uterus  is  normal. 

As  regards  anteflexion  of  the  uterus,  either  the  congenital,  uncom- 
plicated anteflexion  of  the  uterus,  due  to  developmental  anomaly,  or 
the  acquired  form,  due  either  to  subinvolution  of  the  uterus  during 
the  puerperium,  or  to  parametritic  or  perimetritic  processes, —  may 
offer  mechanical  obstacles  to  conception,  and  thus  give  rise  to  steril- 
ity ;  sterility  with  anteflexion  occurs  especially  in  cases  in  which  the 
anteflexion  is  dependent  upon  parametritis  posterior,  associated  with 
metritis  and  endometritis,  or  when  any  other  complication  is  present 
to  make  the  flexion  a  severe  one.  In  some  sterile  women,  we  find 
anteflexion  associated  with  supravaginal  elongation  of  the  porrio, 
and  in  such  cases  both  states  would  appear  to  result  from  catarrh 
of  the  uterine  mucosa.  How  frequent  is  the  combination  of  ante- 


FIG.  80. —  Anteflexio  Uteri.     After  A.  Martin. 

flexion  of  the  uterus  with  sterility,  is  shown  by  the  figures  published 
by  Sims,  who  in  250  cases  of  congenital  sterility  found  103  cases  of 
anteversion,  and  in  255  cases  of  acquired  sterility  found  61  cases  of 
anteversion. 


THE  SEXUAL  EPOCH  OF  THE  MENACME.  519 

Fritsch  writes  in  the  following  terms  regarding  the  difficulty  with 
which  impregnation  is  effected  in  women  suffering  from  anteflexion 
of  the  uterus :  "  In  cases  of  anteflexion  of  the  uterus,  the  vagina  is 
remarkably  long,  the  portio  vaginalis  often  badly  formed ;  the  ejacu- 
lated semen  flows  away  rapidly  from  the  contracted  vagina,  without, 
perhaps,  ever  coming  into  contact  with  the  portio  vaginalis."  He 
states  it  as  a  fact  that  women  with  anteversion  conceive  less  readily 
than  those  with  retroversion  of  the  uterus  (when  this  latter  is 
moderate  in  degree)  ;  for  in  slighter  degrees  of  retroversion,  the 
axis  of  the  uterus  is  a  continuation  of  the  axis  of  the  vagina,  so  that 
the  orifice  of  the  male  urethra  and  the  os  uteri  externum  will  be  in 
contact  during  intercourse  —  more  especially  because  in  such  cases, 
owing  to  the  portio  vaginalis  being  low  in  the  pelvis,  the  vagina  is 
short ;  in  cases  of  anteversion,  on  the  other  hand,  the  cervix  is  high 
up,  and  the  vagina  is  long  and  narrow.  Fritsch  considers  that  gener- 
ally speaking  the  fact  that  the  internal  or  the  external  os  is  small  is 
of  little  importance ;  but  the  serious  factors,  those  leading  to  sterility 
in  cases  of  anteversion  —  apart  from  all  other  considerations  —  are 
the  unfavourable  high  position  of  the  portio  vaginalis,  the  occlusion 
of  the  os  by  the  close  application  of  the  posterior  vaginal  wall,  and 
the  presence  of  glutinous  mucus  in  the  cervical  canal.  Since  in 
cases  of  anteflexion  we  very  commonly  find  hypersecretion  of  the 
uterine  mucous  membrane,  whilst,  owing  to  the  narrowing  of  the 
external  os,  the  mucus  is  unable  to  flow  freely  away,  but  accumu- 
lates and  becomes  inspissated,  we  have  the  uterine  mucous  mem- 
brane covered  with  a  tenacious  coating,  which  may  perhaps  render 
the  implantation  of  the  ovum  a  very  difficult  matter,  even  though 
the  upward  passage  of  the  spermatozoa  be  still  possible.  The  clinical 
association  of  pain  produced  by  drawing  forward  the  portio  vagi- 
nalis, with  marked  anteflexion  of  the  uterus,  dysmenorrhoea,  and 
sterility,  is  a  strikingly  common  one. 

Schroder  points  out  that,  although  sterility  is  common  in  cases 
of  anteflexion,  cases  are  yet  seen  in  which,  notwithstanding  the  ex- 
istence of  extreme  anteflexion,  conception  occurs  very  speedily  after 
marriage.  The  fact  that  in  cases  of  anteflexion  we  have  difficulty, 
not  impossibility,  of  conception,  explains  how  it  is  that  of  two 
women  suffering  from  anteflexion  of  the  same  severity,  one  will 
readily  become  pregnant,  whilst  the  other  remains  permanently 
barren. 

Retroversion  and  retroflexion  offer  obstacles  to  conception  chiefly 
in  cases  in  which  this  displacement  is  a  congenital  anomaly,  or  when 
it  has  developed  immediately  after  puberty ;  or  when  complications 
exist,  especially  when  the  retroflexed  uterus  is  fixed  by  exudation. 
In  nulliparae,  these  deviations  backwards  will  not  rarely  be  found 
to  be  the  cause  of  the  sterility.  Much  less  often  does  sterility  ensue 


520 


THE  SEXUAL  LIFE  OF  WOMAN. 


when  retroversion  or  retroflexion  occurs  in  women  who  have  already 
given  birth  to  several  children,  i.  e.,  when  the  displacement  is  a  puer- 
peral disorder ;  the  reason  why  such  cases  are  not  often  sterile,  is  to 
be  found  in  the  fact  that  the  wide  cervical  canal  favours  the  passage 
of  the  spermatozoa,  and  the  softness  of  the  tissues  prevents  any 
serious  obstacle  to  their  upward  progress  being  offered  at  the  angle 
of  flexion ;  on  the  other  hand,  severe  retroflexion  in  a  woman  who 
has  not-  yet  borne  a  child  offers  a  serious  hindrance  to  conception, 
on  account  of  the  smallness  of  the  cervical  canal,  and  the  sharp 
flexion  of  the  more  rigid  uterus. 

In  general,  then,  retroflexion  can  be  regarded  as  offering  but  a 
slight  hindrance  to  conception.  In  fact,  many  women  with  retro- 
flexion  become  pregnant  again  and  again,  and  may  abort  several 
times  in  a  single  year.  When  in  parous  women  suffering  from  retro- 
flexion,  sterilitv  ultimately  occurs,  B.  Sclniltzc  considers  that  it  is 


FIG.   81. —  Retroflexio  Uteri.     After   A.   Martin. 

not  the  retroflexion  which  is  primarily  to  blame,  but  rather  the 
secondary  consequences  so  common  in  this  disorder :  uterine  catarrh ; 
the  general  constitutional  debility  due  to  such  catarrh,  and  to  the 
accompanying  menorrhagia ;  perimetritis,  and  oophoritis. 

Retroflexion  and  retroversion  of  the  uterus  occur  chiefly  in  women 
who  have  previously  given  birth  to  children ;  the  bend  is  commonly 


THE  SEXUAL  EPOCH  OF  THE  MENACME.  521 

obtuse  or  right-angled,  and  above  the  upper  end  of  the  cervical  canal ; 
sterility  in  such  cases,  usually  acquired,  has  a  favourable  prospect 
of  cure.  As  Kchrer  points  out,  sterility  appears  to  be  constant  only 
in  cases  of  retroflexion  in  which  the  uterus  is  fixed ;  the  reason  prob- 
ably is  that  by  the  backward  inflexion  of  the  uterus  the  abdominal 
orifice  of  the  Fallopian  tube  is  dragged  away  from  the  ovary,  and  thus 
the  ovum,  when  it  is  discharged  from  the  follicle,  fails  to  find  its  way 
into  the  tube. 

Among  57  cases  of  retroflexion  of  the  gravid  uterus,  E.  Martin 
found  that  in  6  the  patient  was  pregnant  for  the  first  time,  from 
which  it  may  be  inferred  that  the  anomaly  existed  prior  to  the  oc- 
currence of  conception. 

That  in  some  cases  of  sterility  it  is  the  retroflexion  of  the  uterus 
that  is  to  blame,  is  shown  very  clearly  ex  juvantibus,  inasmuch  as 
reposition  of  the  uterus  and  maintenance  of  the  organ  in  its  proper 
position  relieves  sterility  perhaps  of  long  standing,  together  with  all 
the  other  troubles  secondary  to  the  displacement  of  the  uterus.  As 
an  example,  I  quote  one  case  from  among  several  of  the  kind  of 
which  I  have  notes.  Mrs.  N.,  25  years  of  age,  married  6  years, 
childless,  suffers  from  severe  dyspeptic  troubles,  leading  to  emacia- 
tion and  profound  depression.  She  has  been  treated  fruitlessly  for 
gastric  catarrh,  but  has  not  previously  been  subjected  to  gynecologi- 
cal examination.  I  insisted  on  making  such  an  examination,  and 
found  the  uterus  somewhat  enlarged  and  completely  retroflexed. 
The  successful  replacement  of  the  organ  was  followed  by  the  cessa- 
tion of  the  previously  constant  vomiting  after  meals,  and  by  the 
disappearance  of  the  other  dyspeptic  troubles ;  shortly  afterwards  the 
lady  became  pregnant,  and  pregnancy  ran  a  normal  course.  Since 
then,  she  has  had  three  children  ;  there  has  been  no  recurrence  of  the 
dyspepsia. 

According  to  Sims,  retroversion  of  the  uterus  is  frequently  asso- 
ciated with  sterility.  Among  250  married  women  who  had  never 
been  pregnant,  we  found  no  less  than  68  cases  of  retroversion ; 
among  255  women  who  had  had  one  or  more  children,  but  had  then 
ceased  to  be  fruitful,  he  found  in  cases  of  retroversion;  and  in 
some  of  these  cases  the  retroversion  was  uncomplicated.  Grenscr 
and  Vcdclcr  also  found  retroflexion  to  be  a  common  cause  of  steril- 
ity ;  the  last-named,  examining  7  nulliparous  married  women,  found 
retroversion  in  5 ;  in  these  cases,  however,  there  was  associated  dis- 
ease of  the  uterus  or  of  its  environment. 

Inversion  of  the  uterus,  even  in  the  minor  degrees  of  the  affection, 
in  which  coitus  is  still  possible,  almost  invariably  causes  sterility, 
owing  to  the  occlusion  of  the  uterine  orifices  of  the  Fallopian  tubes. 
Moreover,  in  inversion  of  the  uterus,  the  position  assumed  by  the 
os  uteri  externum  is  such  as  to  render  the  entrance  of  the  .semen 


522  THE  SEXUAL  LIFE  OF  WOMAN. 

almost  impossible.  Finally,  when  the  uterus  is  inverted,  the  mucous 
membrane  undergoes  changes  which  render  it  unfit  for  the  implan- 
tation of  the  ovum ;  the  researches  of  P.  Ruge  show  that  it  is  thinned 
and  that  the  epithelium  is  cast  off  and  replaced  by  granulation  tissue. 
In  cases  in  which  the  inverted  uterus  has  long  projected  through  the 
genital  fissure,  its  surface  becomes  covered  by  a  multilaminar  pave- 
ment epithelium ;  at  the  same  time,  the  glandular  apparatus  under- 
goes atrophy,  only  the  fundi  of  the  glands  being  preserved,  and  the 
muscular  substance  is  hypertrophied.  None  the  less,  in  exceptional 
cases,  which  have  been  reported  by  Emmet,  Macdonald,  and  Tyler- 
Smith,  pregnancy  has  occurred  after  long-enduring  inversion  of  the 
uterus.  Lauenstein  had  a  patient  in  whom  an  inverted  uterus  was 
replaced  after  a  year  and  a  half;  the  following  week  she  became 
pregnant.  Stevens  saw  a  case  in  which  the  woman  became  preg- 
nant six  months  after  the  reduction  of  an  inversion  of  the  uterus  of 
nine  months'  standing. 

Prolapse  of  the  uterus  is  seldom  the  cause  of  sterility,  inasmuch 
as  during  coitus  replacement  of  the  organ  is  effected.  It  may  even 
be  said  that  in  cases  of  prolapse,  the  low  position  of  the  uterus  and 
the  enlargement  of  the  os  uteri  externum,  favour  the  direct  ejacula- 
tion of  the  semen  into  the  cervical  canal  (likewise  enlarged),  and 
that  thus  the  conditions  are  advantageous  for  impregnation.  In 
fact,  conception  more  commonly  occurs  in  cases  of  prolapse  than 
might  have  been  anticipated  in  view  of  the  various  consecutive  dis- 
orders apt  to  complicate  this  affection — chronic  metritis  and  endo- 
metritis,  erosion,  hypertrophy  of  the  cervix,  displacement  and  lacera- 
tion of  the  annexa,  etc.  The  extent  to  which  the  capacity  for  con- 
ception is  unfavourably  affected  in  cases  of  prolapse  of  the  uterus, 
is  proportional  to  the  amount  of  descent  undergone  by  the  uterus, 
for  the  nearer  the  os  approximates  to  the  vaginal  orifice,  the  farther 
removed  from  the  os  will  be  the  point  at  which  the  semen  is  ejacu- 
lated. In  cases  of  complete  prolapsus  it  has  happened  that  coitus 
has  been  effected  directly  through  the  everted  os  uteri,  and  has  re- 
sulted in  conception ;  a  case  of  this  kind  is  reported  by  Hervey. 

Unbiassed  gynecological  experience  in  no  way  supports  the  views 
of  Sims  and  Hewitt  regarding  the  frequency  with  which  displace- 
ments of  the  uterus  constitute  mechanical  causes  of  sterility.  Sims 
supports  his  views  with  the  figures  previously  quoted,  from  which 
the  following  table  is  compiled: 

Total 
cases  of 

No.  of       Ante-         Retro-     displace- 
cases.      version,     version.       ment. 

First  class 250  103  68  171 

Second  class 255  61  in  172 

Totals 505  164  179  343 


THE  SEXUAL  EPOCH  OF  THE  MENACME.  523 

From  this  it  appears  that  in  the  1st  class,  among  250  married 
women  who  had  never  given  birth  to  a  child,  there  were  103  cases 
of  anteversion,  and  68  cases  of  retroversion ;  whilst  in  the  2nd  class, 
among  255  women,  who  had  had  children,  but  for  one  reason  or 
another  had  become  unfruitful  earlier  than  the  natural  age  for  this 
occurrence,  there,  were  61  cases  of  anteversion,  and  in  cases  of  re- 
troversion. 

The  general  result  of  these  figures  is  to  show  that  two-thirds  of 
all  sterile  wom^n,  without  regard  to  the  especial  cause  of  the  dis- 
placement, suffer  from  one  form  or  the  other  of  uterine  displace- 
ment, and  that  the  relative  frequency  of  anteversions  and  retrover- 
sions  is  reversed  in  the  two  classes,  the  nulliparous  married  women, 
and  the  married  women  previous  parous  but  latterly  become  sterile, 
respectively. 

Hewitt  similarly  regards  malpositions  of  the  uterus  as  frequent 
causes  of  sterility.  He  analysed  296  cases  of  flexion  and  version  of 
the  uterus  treated  by  him  at  University  College  Hospital  during  the 
years  1865  to  1869,  partly  in  the  wards,  and  partly  in  the  out-patient 
department.  Of  these  296  women,  235  were  married ;  100  were 
cases  of  retroflexion,  and  135  were  cases  of  anteflexion.  Of  the  235, 
81  had  had  no  full-term  children,  57  of  the  81  having  never  been 
pregnant,  and  the  remaining  24  having  had  miscarriages  only.  Of 
the  remaining  154,  married  and  parous  women,  %a  large  proportion 
were  sterile  at  the  time  when  they  applied  for  treatment ;  though  in 
the  years  immediately  after  marriage  they  had  given  birth  to  one 
or  more  children,  they  had  subsequently  ceased  to  be  fruitful. 

All  that  these  figures  prove  to  an  unbiassed  judgment  is,  how- 
ever, that  displacements  of  the  uterus  are  apt  to  render  conception 
difficult ;  or  that,  in  addition  to  other  pathological  states  of  the  pelvic 
organs,  they  are  frequently  met  with  in  sterile  women  —  but  in  and 
by  themselves,  displacements  of  the  uterus  do  not  offer  any  very 
serious  or  very  frequently  occurring  obstacle  to  conception. 

That  conception  is  possible  in  spite  of  the  very  notable  mechanical 
hindrances  which  certain  displacements  of  the  uterus  may  offer  to 
the  occurrence  of  pregnancy,  is  shown  by  many  striking  examples 
in  gynecological  literature.  Winckel,  Olshausen,  and  Hoist  have 
all  seen  pregnancy  occur  in  women  who  at  the  time  of  conception 
were  wearing  intra-uterine  pessaries;  and  von  Scanzoni  has  pub- 
lished cases  in  which  fertilization  took  place,  notwithstanding  ex- 
treme anteversion  which  stenosis  of  the  os  uteri,  and  in  another 
instance,  notwithstanding  the  presence  of  a  polypus  filling  the 
external  os. 

Myoma  of  the  Uterus. 

Among  the  mechanical  obstacles  to  conception  which  act  by  pre- 
venting or  rendering  difficult  the  contact  of  spermatozoon  and 


524  THE  SEXUAL  LIFE  OF  WOMAN. 

ovum,  must  be  enumerated  uterine  myomata,  and  these  must  there- 
fore be  included  among  the  causes  of  sterility. 

According  to  their  number,  their  size  and  their  situation,  uterine 
myomata  give  rise  to  different  and  manifold  mechanical  disturb- 
ances. When  there  are  numerous  intra-mural  myomata,  even  when 
these  are  of  a  moderate  size,  the  uterine  cavity  becomes  bent  and 
narrowed,  and  retention  of  the  secretions  may  ensue,  often  lasting 
for  a  lengthy  period.  Submucous  fibromyomata,  when  situated  low 
down,  near  the  internal  os,  may  occlude  this  orifice  completely; 
when  implanted  higher  up  in  the  uterine  cavity,  they  are  apt  to 
cause  flexion  of  the  uterus ;  large,  pedunculated  fibromyomata  of  the 
uterus  may  descend  into  the  vagina  and  narrow  this  passage. 

Myomata  interfere  with  conception  in  very  various  ways.  Me- 
chanically, they  may  occlude  the  uterine  orifices  of  the  Fallopian 
tubes,  or  may  give  rise  to  displacement  of  either  tubes  or  ovaries, 
or,  again,  by  blocking  the  uterine  cavity,  they  may  hinder  the 
descent  of  the  ovum  and  the  upward  passage  of  the  spermatozoa ; 
their  presence  may  cause  catarrhal  disease  of  the  uterine  mucous 
membrane,  or  give  rise  to  profuse  hemorrhage,  and  either  of  these 
secondary  changes  may  interfere  with  the  implantation  of  the  ovum ; 
and  there  is  yet  another  way  in  which  myomata  may  interfere  with 
conception,  and  give  rise  to  sterility  —  this  is  a  subject  to  which 
especial  attention  has  been  given  by  Winckel,  and  to  which  we  may 
here  most  conveniently  allude.  The  continued  growth  of  small 
submucous  myomata  often  gives  rise  to  a  hyperaesthetic  state  of  the 
genital  organs  analogous  to  vaginismus,  and  this  interferes  with 
coitus.  Large  myomata,  on  the  other  hand,  give  rise  to  catarrhal 
states  of  the  uterine  cavity  and  to  hyperplasia  of  the  mucous  mem- 
brane, constituting  hindrances  alike  to  conception,  and  to  the  im- 
plantation and  further  development  of  the  embryo  if  fertilization 
should  be  effected ;  moreover,  the  growth  of  large  myomata  often 
causes  perimetritis,  perisalpingitis,  and  perioophoritis,  and  these, 
partly  by  abnormal  fixation  of  the  uterus,  and  partly  by  closing  up 
the  tubes  and  so  thickening  the  tunics  of  the  ovary  as  to  prevent 
the  rupture  of  the  graafian  follicles,  give  rise  to  sterility. 

The  existing  statistics  regarding  the  relation  of  the  growth  of 
myomata  of  the  uterus  to  fertility,  incomplete  as  they  are  and 
lacking  in  exactitude,  suffice  nevertheless  to  show  that  the  fruit- 
fulness  of  women  suffering  from  uterine  myomata  is  notably  dimin- 
ished by  the  growth  of  these  tumours;  more  particularly,  we  learn 
that  whilst  the  number  of  women  with  uterine  myomata  who  have 
one  child  is  sufficiently  large,  the  number  of  multiparae  thus  affected 
falls  greatly  below  the  average  of  fertility.  A  characteristic  fea- 
ture of  the  influence  of  myomata  in  producing  sterility  is  clearly 
shown  by  the  statistics,  inasmuch  as  pregnancy  is  comparatively 


THE  SEXUAL  EPOCH  OF  THE  MENACME.  525 

common  in  the  case  of  women  with  subserous  myomata,  in  whom 
the  uterine  cavity  and  mucous  membrane  are  as  a  rule  least  affected, 
whilst  fertility  is  far  more  seriously  impaired  in  the  case  of  women 
with  submucous  myomata. 

West,  in  the  case  of  43  married  women  with  myomata  of  the 
uterus,  found  7  childless ;  the  remaining  36  had  in  all  given  birth 
to  only  61  children,  and  20  of  these  had  only  one  child  each.  Of 
Beigel's  patients,  86  married  women  with  uterine  myomata,  21 
were  sterile;  of  McClintock's  21  patients  similarly  situated,  10 
were  sterile.  Von  Scansoni's  investigation  showed  38  sterile  women 
among  60  married  women  suffering  from  myoma  uteri ;  Michel,  26 
sterile  among  127;  Winckcl,  134  sterile  among  415.  From  a  table 
showing  the  number  of  children  born  to  each  of  108  women  with 
myoma  uteri  of  whom  46  were  observed  by  Winckel,  and  62  were 
in  Silsserott's  collection,  it  appears  that  on  an  average  2.7  children 
were  born  to  each  woman  thus  affected,  whereas  in  Saxony  the 
average  number  of  children  born  to  each  married  woman  is  4.5. 

Many  other  gynecologists  have  published  statistics  regarding  this 
matter,  Gusserow,  Rohrig,  Schroder,  E.  von  Flamerdinghe,  and 
others,  some  of  them  dealing  with  a  very  large  number  of  cases, 
and  all  show  that  30^  and  upwards  of  married  women  with  uterine 
myomata  remain  sterile. 

On  the  other  hand,  Hofmeier  maintains,  in  opposition  to  the 
prevailing  view,  that  in  the  great  majority  of  cases  myomata  are 
not  to  be  regarded  as  giving  rise  to  sterility.  His  investigation 
embraced  313  persons,  of  whom  25$  were  unmarried,  and  75^ 
married,  and  of  these  latter,  25  to  30$  were  sterile.  (It  must  be 
pointed  out  that  compared  with  the  average  percentage  of  sterile 
marriages  —  about  10^,  this  figure^of  25  to  30$  is  a  very  high  one.) 
From  a  comparison  of  the  age  of  the  sterile  married  woman  with 
the  duration  of  married  life  in  each  case,  Hofmeier  is  led  to  believe 
that  it  is  not  the  myomata  which  have  exercised  an  influence  un- 
favourable to  fertility,  and  that  the  occurrence  of  sterility  in  these 
cases  is  referable  to  other  causes.  The  origination  of  myomata 
he  regards  as  etiologically  independent  of  the  exercise  or  non- 
exercise  of  the  sexual  act.  The  apparently  overwhelming  pre- 
ponderance of  the  occurrence  of  myomata  in  unmarried  and  in 
sterile  married  women  is,  he  thinks,  to  be  explained  by  the  fact 
that  unmarried  women  and  nulliparous  married  women  seldom  have 
occasion  to  consult  a  gynecologist,  but  that  the  one  condition  that 
lenders  it  necessary  for  them  to  do  so  is  the  growth  of  a  uterine 
myoma.  Generally  speaking,  pregnancy  seldom  occurs  after  the 
age  of  35  years,  precisely  the  age  at  which  the  growth  of  uterine 
myomata  begins  to  be  common.  If,  however,  at  this  comparatively 
late  age  pregnancy  does  occur,  it  is  so  often  found  to  be  complicated 


526  THE  SEXUAL  LIFE  OF  WOMAN. 

by  the  presence  of  a  uterine  myoma,  that  Hofmeier  is  even  led  to 
infer  that  the  presence  of  such  a  tumour  must  have  a  certain  favour- 
ing influence  upon  the  occurrence  of  conception;  the  facilitation  of 
conception  in  these  cases  he  explains  by  the  fact  that  the  growth 
of  the  tumour  renders  the  blood  supply  of  the  whole  reproductive 
apparatus  more  active  than  is  normally  the  case,  and  protracts  the 
duration  of  ovarian  activity. 

Diseases  of  the  Vagina  and  the  Vulva. 

Various  pathological  states  of  the  vagina  and  vulva  may  cause 
incapacity  for  fertilization  by  rendering  copulation  impossible. 
Such  states  may  be  either  congenital  or  acquired. 

In  rare  cases  the  hindrance  consists  in  abnormal  smallness  of 
the  vulva,  but  this  condition  is  usually  associated  with  other  defects 
in  development  of  the  reproductive  organs,  which  combine  to  give 
rise  to  sterility.  Congenital  adhesion  of  the  labia  minora  and 
majora  is  sometimes  met  with,  with  or  without  atresia  of  the 
urethral  orifice,  the  connexion  between  the  labia  may  be  super- 
ficial and  epithelial  merely,  as  in  a  case  recorded  by  Ziemssen;  or 
the  labia  may  be  firmly  united  throughout  their  whole  thickness. 
Much  less  common  is  acquired  adhesion  of  the  labia,  causing  atresia 
vulvae,  and  rendering  coitus  difficult  or  entirely  impossible.  Vari- 
ous other  abnormalities  of  the  reproductive  organs  which  may  give 
rise  to  sterility  have  already  been  described  in  the  section  on  the 
pathology  of  cohabitation,  these  are :  abnormalities  of  the  hymen ; 
anomalous  formation  and  hypertrophy  of  the  labia;  excessive  size 
of  the  clitoris ;  anomalies  of  the  vagina,  its  absence,  stenosis,  atresia, 
duplication,  and  abnormal  termination. 

More  detailed  mention  must,  however,  be  made  here  of  vesico- 
vaginal  fistula  as  leading  to  sterility.  Such  a  fistula  is  rightly  re- 
garded as  one  of  the  conditions  preventing  conception,  but  it  does 
not  render'  the  occurrence  of  pregnancy  absolutely  impossible.  It 
will  readily  be  understood  that  the  unpleasant  symptoms  commonly 
met  with  in  these  cases,  will  be  apt  to  deprive  both  husband  and 
wife  of  inclination  toward  sexual  intercourse ;  again,  apart  from 
this  psychical  influence,  the  functions  of  the  female  reproductive 
apparatus  are  commonly  disturbed  to  a  very  serious  degree  by  the 
existence  of  a  vesico-vaginal  fistula ;  and,  finally,  the  unfavourable 
influence  of  the  urine  on  the  semen  must  also  be  taken  into  con- 
sideration, for,  as  an  acid  fluid,  the  urine  will  notably  check  the 
activity  of  the  movements  of  the  spermatozoa  —  still,  notwithstand- 
ing all  these  unfavourable  influences,  conception  will  sometimes 
nevertheless  occur  in  such  cases.  But  of  those  who  acquire  a  vesico- 
vaginal  fistula  as  the  result  of  a  difficult  labour,  a  very  small  pro- 
portion only  will  again  become  pregnant. 


THE  SEXUAL  EPOCH  OF  THE  MENACME.  527 

Freund  draws  attention  to  Simon's  experiences,  reminding  us 
that  the  latter,  in  his  cases  in  which  women  with  vesico-vaginal 
fistula  become  pregnant,  invariably  saw  the  pregnancy  terminate 
in  abortion  or  premature  labour;  but  still,  Freund  quotes  also  a 
case  of  Schmitt's,  and  mentions  another  of  his  own,  showing  that 
this  premature  termination  of  the  p"egnancy  is  not  absolutely  in- 
evitable in  such  circumstances.  Schroder,  indeed,  goes  far  in  the 
opposite  direction,  and  writes :  "  Such  women  not  rarely  become 
pregnant,  and  their  pregnancy  usually  runs  a  normal  course." 
Kroner  made  a  statistical  investigation  of  the  question,  and  found 
that  of  60  women  suffering  from  vesico-vagin'al  fistula,  6  became 
pregnant  during  the  persistence  of  the  fistula.  Winckel  reports  a 
remarkable  case  in  which,  after  the  ordinary  means  of  curing  the 
fistula  had  been  vainly  tried,  transverse  obliteration  of  the  vagina 
was  undertaken ;  the  operation  was  not  completely  successful,  as  a 
small  passage  remained  patent;  the  patient  returned  home  for  a 
time,  and  became  pregnant,  the  spermatozoa  having  found  their 
way  through  this  passage.  Simon  reports  another  noteworthy  case, 
that  of  a  woman  57  years  of  age,  with  a  vesico-vaginal  fistula  close 
to  the  external  os ;  during  the  26  years  the  fistula  had  lasted  she  had 
complained  of  cessatio  mensium;  when  the  fistula  was  closed  by 
operation,  she  again  began  to  menstruate. 

Sometimes  we  meet  with  abnormalities  of  the  vagina  —  not 
strictly  speaking  morbid  states  —  which,  though  they  may  not  at 
first  sight  appear  to  be  of  much  significance,  yet  suffice  to  render 
conception  difficult,  or  even  impossible.  One  of  these  conditions  is 
extreme  shortness  of  the  vagina,  leading  to  the  formation  of  a 
"poche  copulatrice"  (Courty),  in  which  during  coitus  the  semen 
is  ejaculated  at  a  distance  from  the  os  uteri  externum ;  another  is 
excessive  length  and  width  of  the  vagina ;  another,  some  displace- 
ment of  the  vagina  which  diminishes  the  prospect  that  the  semen 
will  enter  the  cervical  canal.  Such  vagina.1  false  passages,  "  fausses 
routes  vaginales,"  have  been  described  more  especially  by  Pajot  as 
causes  of  sterility. 

Another  cause  of  sterility  is  the  rapid  outflow  of  the  semen  after 
coitus,  either  in  consequence  of  dyspareunia,  or  on  account  of  some 
abnormality  in  the  configuration  of  the  vagina,  or,  finally,  owing  to 
deficient  action  of  the  constrictor  cunni  (or  bulbocavernosus  mus- 
cle) and  the  muscles  of  the  pelvic  diaphragm.  In  cases  of  pro- 
fluvium  seminis,  the  woman  herself  will  often  call  the  physician's 
attention  to  the  defect. 

Many  cases  of  sterility  depend  upon  a  cause  the  recognition  of 
which  in  this  connexion  is  comparatively  recent,  namely,  the  herma- 
phroditism  of  the  person  concerned.  Witness  the  following  case 
described  by  Dohrn:  The  individual  had  been  baptised  and  brought 


528  THE  SEXUAL  LIFE  OF  WOMAN. 

up  as  a  girl.  At  the  age  of  twenty  years  she  began  to  suffer  from 
a  distressing  sensation  of  pressure,  recurring  at  intervals  of  four 
weeks.  A  local  examination  was  made  by  a  physician,  who  assured 
the  mother  that  "  there  was  no  hindrance  to  menstruation,  but 
that  when  she  married  an  incision  would  become  necessary."  After 
a  time  she  became  engaged  and  was  married;  and  shortly  after- 
wards her  husband  demanded  a  renewed  gynecological  examination. 
This  was  undertaken  by  Dohrn,  who  declared  that  the  supposed 
girl  was  of  the  male  sex.  The  external  reproductive  organs*  had 
the  feminine  form.  The  labia  majora  were  large  and  well-formed; 
in  the  anterior  extremity  of  each  labium  was  a  rounded,  sensitive, 
soft  body,  of  the  size  of  a  large  bean,  which  was  capable  of  being 
drawn  forwards  towards  the  abdomen;  the  labia  were  beset  with 
muscular  fibres;  the  clitoris  was  4  cm.  (1.6  in.)  in  length,  resemb- 
ling an  imperforate  infantile  penis,  it  was  slightly  erectile ;  in  the 
vestibule  there  were  two  openings,  the  anterior  of  which  was  the 
urethra,  the  posterior  led  into  a  blind  passage  2  cm-.  (0.8  in.)  in 
length,  representing  the  fused  lower  extremities  of  the  ducts  of 
Miiller;  per  rectum  no  trace  could  be  found  of  vagina,  uterus,  or 
ovaries,  but  also  no  trace  of  prostate.  The  marriage,  in  which  this 
individual  declared  himself  to  be  happy,  was  annulled.  Leopold 
observed  a  similar  case,  in  which  the  individual  had  lived  as  a  wife 
for  the  space  of  25  years.  Another  striking  case  is  recorded  by 
Steglehncr.  As  Zweifcl  remarks,  to  decide  the  true  sex  of  such 
individuals  is  often  extremely  difficult.  "At  the  present  day,  in- 
deed," he  continues,  "  it  is  no  longer  the  fate  of  those  who  from  no 
fault  of  their  own  have  had  imposed  on  them  the  name  and  up- 
bringing of  another  sex  than  that  which  is  truly  theirs,  and  who 
have  thus  been  led  to  contract  marriage  with  one  who  in  reality  is 
of  their  own  sex,  to  be  treated  with  the  horrible  injustice  which  was 
meted  out  to  them  in  the  middle  ages,  when,  as  we  learn  from  con- 
temporary writers,  they  were  haled  before  the  bar  of  "  ecclesiastical 
justice,"  charged  with  profaning  the  sacrament  of  marriage,  and 
threatened  with  death  at  the  stake  —  but  even  now  a  mistake  in  the 
decision  of  an  infant's  sex  entails  in  later  life  a  thousand  distresses 
and  inconveniences." 

Recently,  Neugcbauer  has  made  as  complete  a  collection  as  pos- 
sible of  all  the  recorded  cases  of  hermaphroditism. 

Secretions  of  the  Genital  Organs. 

The  constitution  of  the  secretion  of  the  vaginal  mucous  mem- 
brane, or  of  the  secretion  formed  in  the  cervical  canal,  or  both  of 
these  in  combination,  may  constitute  hindrances  to  the  normal  con- 
tact of  spermatozoon  and  ovum. 


THE  SEXUAL  EPOCH  OF  THE  MENACME.  529 

The  secretions  of  the  female  genital  organs  are  manifold.  The 
outer  surface  of  the  labia  majora  is  covered  with  skin,  containing 
sebaceous  and  sweat  glands ;  but  the  inner  surface  of  the  labia 
majora  and  the  rest  of  the  external  genital  organs  are  covered  with 
mucous  membrane,  the  outer  stratum  of  which  consists  of  strati- 
fied pavement  epithelium;  this  epithelium  contains  sebaceous  glands 
and  mucus  glands.  The  intermixture  of  the  secretions  of  these 
glands  with  the  epithelial  scales  which  are  constantly  being  cast  off 
in  large  numbers,  constitutes  the  whitish  material  with  which  this 
region  is  smeared,  known  as  "  smegma."  A  mucus  -secretion  of 
a  fluid  consistency  is  discharged  from  the  vulvo-vaginal  glands 
known  by  the  name  of  Bartholin's  glands. 

The  mucous  lining  of  the  vagina  is  poor  in  glands;  it  contains 
very  numerous  papillae,  which  do  not,  however,  project  from  the 
surface  of  the  membrane,  since  the  depressions  between  the  papillae 
are  filled  in  by  the  stratified  epithelium  with  which  the  entire  extent 
of  the  vaginal  mucous  membrane  is  covered.  The  secretion  of  the 
vaginal  mucous  membrane  is  a  fluid  of  thin  consistency  with  an 
acid  reaction ;  the  admixture  of  numerous  morphological  elements, 
in  the  form  of  epithelial  cells  cast  off  from  the  superficial  layers  of 
the  stratified  epithelium,  often,  however,  makes  the  vaginal  secretion 
thick  and  opaque.  The  epithelial  lamellae  are  frequently  covered 
with  heaps  of  lepthothrrx  granules,  and  among  the  granules  are 
seen  vibriones  and  bacteria  and  also  numerous  lepthothrix  threads 
of  varying  length. 

The  same  stratified  epithelium  extends  on .  to  the  neck  of  the 
uterus  to  a  distance  which  varies  in  different  individuals ;  gradually, 
however,  the  number  of  layers  diminishes,  the  flattened  cells  give 
place  to  thicker,  prismatic  cells,  until  we  have  a  single-layered  pris- 
matic epithelium ;  finally  the  cells  become  columnar  and  ciliated, 
and  this  columnar  ciliated  epithelium  covers  the  whole  of  the  in- 
terior of  the  uterus.  The  mucous  lining  of  the  cervical  canal  con- 
tains numerous  mucous  glands,  some  of  which  are  simple  tubular 
glands,  whilst  others  are  racemose ;  they  are  lined  with  columnar 
ciliated  epithelium,  and  secrete  a  dense,  gelatinous,  alkaline  mucus, 
containing  a  few  epithelial  cells  and  occasional  leucocytes.  The 
mucous  membrane  of  the  uterine  cavity  is  beset  with  simple  tubular 
•  glands,  lined  with  a  single  layer  of  prismatic  epithelium ;  these 
glands  secrete  a  grayish  alkaline  fluid.  The  secretion  formed  in 
the  uterine  cavity  is  thinner  in  consistency  than  that  formed  in  the 
cervical  canal. 

Normally,  the  secretion  of  the  vaginal  mucous  membrane  is  not 
more  than  is  sufficient  to  keep  the  surface  of  the  canal  moist  and 
slippery ;  it  is  a  thin  fluid  of  an  acid  reaction,  and  almost  as  clear 
as  water.  Shortly  before  and  after  menstruation,*  the  secretion  of 

34 


530  THE  SEXUAL  LIFE  OF  WOMAN. 

the  vaginal  mucous  membrane  becomes  more  abundant;  it  is  even 
thinner  than  at  other  times;  the  reaction  remains  acid.  The  secre- 
tion of  the  cervical  canal  is  normally,  in  the  absence  of  sexual 
intercourse,  small  in  amount,  so  that  a  free  flow  of  secretion  from 
the  os  uteri  externum  is  by  itself  sufficient  to  indicate  that  the  mucous 
membrane  of  the  canal  is  in  an  abnormal  condition.  The  vitreous, 
gelatinous,  alkaline  mucus  secreted  by  the  glands  of  the  cervical 
canal  is  normally  retained  within  the  canal,  and  is  seen  on  exam- 
ination with  the  speculum  to  fill  the  os  uteri  externum.  In  conse- 
quence of  the  congestion  of  the  uterus  that  occurs  during  men- 
struation, and  for  the  same  reason  during  sexual  excitement,  the 
secretion  of  the  cervical  canal  is  more  abundant,  it  also  becomes 
less  tenacious,  and  flows  out  through  the  os  into  the  vagina.  But 
this  evacuation  of  the  cervical  secretion  through  the  os  is  a  normal 
occurrence  only  during  menstruation  and  as  a  result  of  sexual  inter- 
course; in  these  circumstances  it  appears  in  the  form  of  a  clear 
or  somewhat  yellowish  drop  of  fluid  exuding  through  the  os  uteri 
externum. 

In  catarrhal  states,  the  secretions  of  the  genital  passage,  like 
those  of  other  mucous  membranes,  become  abnormal.  There  is  an 
increase  in  the  number  both  of  epithelial  elements  and  of  leucocytes  ; 
and  in  very  acute  catarrhs,  erythrocytes  also  mingle  with  the  secre- 
tion. On  microscopical  examination  we  find  that  the  catarrhal 
secretion  differs  in  its  characters  according  to  the  part  from  which 
it  is  derived :  the  mucus  from  the  cervical  canal  forms  gelatinous 
accumulations ;  that  from  the  vaginal  mucous  membrane  forms  thick 
opaque  masses;  and  in  the  mixed  secretion  which  exudes  from  the 
vulva,  we  find  also  smegma  from  the  external  genital  organs.  In 
addition  to  cells  from  the  laminated  epithelium,  .we  see  often  young 
cells,  somewhat  oval  or  polyhedral  in  form,  with  granular  pro- 
toplasm, and  a  vesicular  nucleus.  In  some  inflammatory  states, 
pus  corpuscles  will  also  make  their  appearance.  Various  micro- 
organisms are  in  addition  to  be  found  in  the  catarrhal  secretions. 

The  reaction  of  the  vaginal  secretion  is  normally  faintly  acid ; 
should  it  become  strongly  acid,  the  movements  of  the  spermatozoa 
are  immediately  suspended.  The  mucus  of  the  cervical  canal,  the 
alkaline  reaction  of  which  is  extremely  favourable  to  the  onward 
movement  of  the  spermatozoa,  may,  owing  to  catarrhal  processes, 
be  so  altered  that  it  becomes  acid ;  it  then  destroys  the  spermatozoa, 
and  gives  rise  to  sterility.  This  fact  can  sometimes  be  proved  by 
microscopical  examination.  In  several  cases  in  which  endometritis 
existed  in  sterile  women  I  made  a  microscopical  examination  of  the 
cervical  mucus  shortly  after  the  completion  of  sexual  intercourse ; 
and  in  a  number  of  these,  no  living  spermatozoa  were  to  be  seen, 
but  only  dead,  mbtionless  spermatozoa  (Fig.  82).  I  had,  of  course, 


THE  SEXUAL  EPOCH  OF  THE  MENACME.  531 

in  these  cases,  previously  assured  myself  that  the  husband's  semen 
was  normally  active. 


FIG.  82. 

Mucus  from  the  Cervical  Canal,  taken  one  hour  after  sexual  intercourse, 
from  a  woman  suffering  from  chronic  endometritis. 

Among  the  epithelial  cells,  pus  cells,  and  finely  granular  masses,  we  see  a 
few  motionless,  dead  spermatozoa. 

According  to  Noggerath,  in  cases  of  uterine  catarrh,  we  may 
find  one  of  three  different  varieties  of  secretion.  In  some  cases  it 
is  small  in  amount,  and  very  thin  in  consistency ;  in  others,  it  is 
moderate  in  amount,  very  thick,  non-transparent,  bright  yellow,  and 
gelatinous  in  consistency ;  in  the  third  class  of  cases,  we  have  num- 
erous degrees  of  variation,  starting  from  the  normal,  purely  mucus, 
transparent  secretion,  mixed  with  yellow  flocculae,  up  to  a  secretion 
which  has  almost  the  aspect  of  pure  pus.  The  first  described 
variety  is,  according  to  Noggerath,  met  with  chiefly  in  women  whose 
uteri  are  small,  with  indurated  tissues3  and  its  discharge  seems  to 
depend  upon  commencing  atrophy  of  the  mucous  membrane.  The 
second  form  is  the  most  obstinate,  the  catarrh  being  situated  chiefly 
in  the  cervical  and  probably  also  the  uterine  glands ;  whereas  the 
first  variety  of  secretion  is  rather  a  serous  transudation,  and  con- 
tains very  few  formed  elements.  The  third  form  is  characterized 
by  extensive  denudation  of  the  superficial  epithelium,  and  is  mixed 
with  a  smaller  or  larger  quantity  of  pus. 

Levy,  who  made  microscopical  examinations  in  sterile  women 
(39  cases),  gives  it  as  a  "constant  fact"  that  when  the  cervical 
secretion  contains  epithelial  and  pus  cells  in  large  quantities,  the 
spermatozoa  never  retain  for  long  their  power  of  movement. 
Whereas  in  examinations  made  repeatedly  on  healthy  women  25 
hours  after  sexual  intercourse,  he  found  numerous  spermatozoa 


532  THE  SEXUAL  LIFE  OF  WOMAN. 

still  in  active  movement,  in  women  having  a  catarrhal  discharge 
with  the  characters  just  mentioned,  five  hours  after  intercourse  the 
movements  of  the  spermatozoa  had  almost  entirely  ceased. 

Not  only  may  the  secretions  of  the  genital  passage  be  injurious 
to  the  spermatozoa  by  their  quality,  but  further  a  very  abundant 
secretion  may  interfere  with  fertilization.  In  the  first  place  a  very 
abundant  secretion  is  apt  to  be  very  dilute,  and  if  the  spermatozoa 
are  immersed  in  a  fluid  of  which  the  specific  gravity  is  too  low,  they 
swell  up  from  imbibition  of  water,  and  their  movements  are  sus- 
pended. But  excessive  secretion,  such  as  is  sometimes  met  with 
in  cases  of  cervical  catarrh,  may  also  have  a  purely  mechanical 
deleterious  action,  by  washing  away  the  semen  out  of  the  vagina. 
If,  again,  the  quantity  of  the  ejaculated  semen  is  unusually  small, 
contact  with  the  normally  acid  vaginal  mucus  may  suffice  to  render 
the  spermatozoa  speedily  motionless.  Finally,  when  the  cervical 
secretion  is  of  a  too  tenacious  consistency,  so  that  it  fills  the  os  as 
with  a  plug,  the  upward  passage  of  the  spermatozoa  may  be  barred. 

Such  tenacious  cervical  mucus  will  give  rise  to  sterility  especially 
in  women  who  have  not  previously  born  children ;  whereas  in 
parous  women,  owing  to  the  more  patulous  condition  of  the  os,  the 
entrance  of  the  spermatozoa  is  not  so  effectually  prevented.  The 
same  distinction  between  nulliparous  and  parous  women  must  be 
made,  as  von  Scansoni  has  pointed  out,  also  as  regards  the  pro- 
duction of  sterility  by  hypersecretion  of  uterine  mucus.  Women 
who  become  affected  with  uterine  blenorrhoea  only  after  having  had 
one  or  more  children,  will  readily  become  pregnant  again;  but 
when  such  blenorrhoea  affects  a  woman  who  has  never  been  preg- 
nant, sterility  almost  invariably  results. 

Von  Griinewaldt  has  drawn  attention  to  a  somewhat  rare  form  of 
chronic  endometritis  with  tenacious  secretion,  leading  to  sterility. 
The  shape,  size,  and  consistency  of  the  uterus  appear  normal,  the 
organ  is  often  virginal,  but  with  the  speculum  we  see  exuding  from 
the  os  a  greyish  green,  extremely  tenacious  secretion,  which  is  wiped 
away  with  difficulty.  He  saw  24  women  affected  with  this  disease ; 
10  of  these  had  lived  in  marital  intercourse  for  many  years  without 
ever  having  become  pregnant ;  in  10  others  there  was  acquired  ster- 
ility, i.  e.,  they  had  at  first  borne  children  after  marriage,  but  had 
subsequently  ceased  to  be  fruitful ;  in  the  remaining  4  it  was  not 
possible  to  ascertain  whether  they  were  fruitful  or  sterile,  since 
two  of  them  were  living  apart  from  their  husbands,  whilst  in  the 
case  of  the  other  two  only  two  years  had  elapsed  since  the  birth  of 
the  last  child.  In  any  case,  not  one  of  the  women  thus  affected  had 
ever  become  pregnant  subsequent  to  the  time  at  which  she  acquired 
this  form  of  endometritis,  notwithstanding  the  fact  that  in  several 
of  the  cases  the  symptoms  were  alleviated  by  treatment. 


THE  SEXUAL  EPOCH  OF  THE  MENACME.  533 

We  must  here  consider  also  the  effect  of  gonorrhoeal  infection  in 
giving  rise  to  sterility  in  women.  Sterility  may  arise  from  gonor- 
rhoea in  women  in  various  ways.  Sometimes  the  abundance  of  the 
cervical  secretion  is  alone  sufficient  to  prevent  the  entrance  of  the 
spermatozoa  into  the  uterus;  in  other  cases  the  hindrance  to  fer- 
tility depends  upon  the  inflammatory  conditions  in  the  pelvis  that  so 
frequently  result  from  gonorrhoeal  infection  —  perimetritis  and 
parametritis ;  it  may  be  catarrhal  changes  in  the  tubes  —  salpingitis, 
hydrosalpinx,  and  pyosalpinx  —  by  which  the  contact  between 
spermatozoon  and  ovum  is  prevented.  Chronic  gonorrhoeal  en- 
dometritis  may  give  rise  to  such  changes  in  the  uterine  mucous 
membrane  as  to  unfit  it  permanently  for  the  implantation  of  the 
ovum,  even  should  there  be  no  obstacle  to  fertilization.  Finally, 
double  gonorrhoeal  oophoritis  may  result  in  rendering  the  forma- 
tion of  mature  ovum  an  entire  impossibility  —  bringing  about  a 
condition  analogous  to  azoospermia  in  the  male,  and  causing  abso- 
lute sterility.  Although  in  many  cases  the  detection  of  the  gono- 
coccus  affords  indisputable  evidence  of  the  existence  of  gonorrhoeal 
infection,  it  must  be  remembered  that  it  is  often  difficult,  and  some- 
times entirely  impossible,  to  make  the  diagnosis  with  certainty ;  and 
for  this  reason  it  is  possible  that  gonorrhoeal  infection  plays  a 
much  larger  part  in  the  causation  of  sterility  than  has  until  lately 
been  believed. 

The  observant  physician  will  in  cases  of  sterile  marriage  fre- 
quently find  in  husband  or  wife  or  both,  evidence  of  previous  or  still 
existent  gonorrhoea ;  but  he  will  cautiously  weigh  all  the  circum- 
stances before  deciding  that  such  gonorrhoeal  infection  is  the 
efficient  cause  of  the  sterility.  In  many  cases,  however,  the 
etiological  relation  is  too  obvious  to  be  overlooked,  and  we  can 
trace  all  the  distresses  of  the  unfortunate  wife  to  the  injury  she 
unwittingly  received  upon  the  momentous  wedding  night. 

Still,  we  have  to  remember  how  extraordinarily  common,  more 
especially  in  the  so-called  upper  classes  of  society,  is  gonorrhoeal 
infection,  and  what  an  enormous  percentage  of  men  entering  upon 
married  life  have  previously  experienced  one  or  more  attacks  of  the 
disease  • —  so  that  were  sterility  a  frequent  sequel  of  such  infection, 
fertility  would  be  the  exception  rather  than  the  rule.  By  inquiry 
among  friends  and  patients  as  to  whether  when  they  married  they 
had  previously  suffered  from  gonorrhoea,  in  conjunction  with  in- 
formation regarding  the  fruitfulness  of  their  marriages,  I  have  been 
led  to  the  conclusion,  which  appears  to  me  to  be  one  of  considerable 
importance,  that  the  proportion  of  sterile  to  fruitful  women  among 
the  wives  of  men  who  have  suffered  from  gonorrhoea  before  mar- 
riage, is  about  the  same  as  the  proportional  fertility  of  all  marriages 
considered  independently  of  gonorrhoeal  infection,  viz.  I  :io.  This 


534  THE  SEXUAL  LIFE  OF  WOMAN. 

depends,  as  it  appears  to  me,  not  only  upon  the  fact  that  very  fre- 
quently in  men  gonorrhoea  is  completely  cured,  but  also  upon  the 
fact  that  in  women  gonorrhoeal  infection  does  not  necessarily  cause 
sterility.  It  may  indeed  be  regarded  as  definitely  established  that 
women  actually  suffering  from  gonorrhoea  may  become  pregnant, 
and  that  the  pregnancy  may  proceed  to  its  natural  termination. 
The  recent  investigations  regarding  the  frequency  with  which  gqno- 
cocci  may  be  detected  in  the  genital  secretions  of  pregnant  and 
parturient  women  —  and  they  are  to  be  found  in  a  surprisingly 
large  percentage  —  suffice  to  prove  that  gonorrhoeal  infection 
offers  no  insuperable  obstacle  to  conception.  That  the  discovery  of 
gonococci  in  a  man's  urethra  does  not  justify  us  with  apodictic 
certainty  in  forbidding  the  man  thus  affected  to  marry  is  in  fact 
proved  by  the  following  remarkable  case,  which  came  within  my 
own  experience.  A  young  man  who  had  had  several  attacks  of 
acute  gonorrhoea,  wishing  to  marry,  had  himself  examined  by  two 
specialists  in  genito-urinary  disease.  Both  detected  gonococci  in 
his  urethra,  and  both  forbade  him  to  marry.  The  patient,  however, 
would  not  be  advised,  and  married  the  lady  of  his  choice ;  now,  six 
years  after  marriage,  he  is  the  happy  father  of  four  blooming  chil- 
dren, and  his  wife  is  in  perfect  health. 

Gosselin,  in  an  elaborate  work  published  in  1853,  was  the  first  to 
point  out  the  serious  consequences  as  regards  a  man's  future 
potentia  generandi  which  are  entailed  by  an  attack  of  gonorrhoea 
followed  by  epididymitis.  He  insisted  that  the  inflammation  might 
lead  to  the  obliteration  at  some  point  of  the  vas  deferens,  whereby 
the  secretion  of  the  testicle  was  prevented  from  mixing  with  the 
secretions  of  the  prostate,  Cowper's  gland,  and  the  seminal  vesicle; 
and  hence  the  ejaculated  sperm  was  lacking  in  its  principal  con- 
stituent. In  such  cases,  either  in  the  epididymis  (usually  in  the 
globus  minor  of  that  organ),  or  else  in  the  course  of  the  vas  de- 
ferens, somewhere  between  the  epididymis  and  the  vesicula  semin- 
alis,  some  relic  of  the  former  inflammation  is  usually  to  be  detected, 
the  globus  gonorrhoeicus,  and  this  usually  represents  the  seat  of 
strangulation  of  the  excretory  duct  of  the  testicle. 

In  the  year  1872  Noggerath  published  his  book,  written  with 
flaming  fiery  zeal,  entitled  "  Latent  Gonorrhoea  in  the  Female  Sex." 
In  the  most  startling  colours  he  depicted  all  the  misery  and  distress 
which  formed  the  wedding  gift  of  the  gonorrhoea-infected  husband 
to  his  wife ;  when  sowing  his  wild  oats,  such  a  husband  is  preparing 
for  the  crop  by  which  his  young  wife's  happiness  is  destroyed,  her 
health  ruined,  her  life  endangered,  and  her  hopes  of  offsprings 
annulled.  While  we  may  admit  that  Noggcrath's  motives  were  of 
the  noblest,  we  cannot  but  wonder  that  the  wickedness  of  the  male 
sex  has  not  yet  entailed  the  destruction  of  the  whole  human  race, 
overwhelmed  as  by  a  new  fall  of  Sodom  and  Gomorrah. 


THE  SEXUAL  EPOCH  OF  THE  MENACME.  535 

Noggcrath  maintained  that  90$  of  men  infected  with  gonorrhoea 
remained  uncured;  and  that  of  the  women  married  by  men  thus 
permanently  infected  with  gonorrhoea,  barely  10$  remained  free 
from  the  disease.  It  is  gonorrhoeal  infection,  of  which  this  author 
gives  so  gloomy  a  picture,  which  is,  in  his  opinion,  the  principle 
cause  of  sterility  in  women.  According  to  his  observations,  of  81 
women  thus  infected,  49  remained  absolutely  sterile;  only  31  be- 
came pregnant ;  23  were  delivered  at  full  term,  3  had  miscarriages, 
and  5  premature  delivery.  Thus,  not  so  many  as  I  in  3  of  these 
women  had  a  full-time  child.  Of  the  23  who  were  delivered  at  full 
term,  12  never  had  more  than  I  child  each;  7  had  2  children  each; 
3  had  3  children  each ;  I  only  had  4  children,  the  normal  average 
fruit  of  healthy  marriages.  In  all,  the  81  women  had  only  39 
children.  If  we  take  4  to  be  the  average  number  of  the  offspring 
cf  a  healthy  married  pair,  there  was  but  one  normal  woman  among 
the  whole  81.  Forty-nine  were  absolutely  sterile;  u  of  the  re- 
mainder had  I  child,  and  did  not  again  conceive  during  periods 
ranging  from  3  to  18  years  after  the  recorded  delivery;  thus  there 
were  60  sterile  women  among  81. 

Noggerath's  doctrine  regarding  the  relation  between  gonorrhoeal 
infection  and  sterility  obtained  at  first  little  credence  —  perhaps  for 
the  reason  that  he  drew  such  far-reaching  conclusions  from  so 
limited  a  material  —  Schroder  mentions  Noggerath's  opinions  only 
to  dismiss  them  as  extravagant ;  but  the  idea  that  the  husband  was 
mainly  to  blame  for  the  occurrence  of  sterility  in  marriage  con- 
tinued to  form  the  topic  of  scientific  discussion.  The  indignation 
which  Noggerath's  assertions,  unquestionably  too  sweeping,  had 
aroused  in  gynecological  circles,  gradually  subsided,  as  every 
gynecologist  devoted  his  attention  to  supporting  or  refuting  Nog- 
gerath's conclusions. 

It  soon  became  evident,  that  gonorrhoea  in  the  male  had  a  dele- 
terious influence  upon  the  fertilizing  quality  of  the  semen,  and  this 
far  more  frequently  than  had  previously  been  supposed.  Filr- 
bringcr,  as  a  result  of  the  examination  of  124  cases,  laid  down  the 
important  proposition,  that  when  epididymitis  or  funiculitis  gonor- 
rhoeica  duplex  had  been  observed  to  occur,  the  probability  that  the 
patient  would  be  an  azoospermist  was  expressed  by  the  ratio  of  9:1, 
and  this  in  direct  opposition  to  the  views  of  Zeissl,  who  had  main- 
tained that  in  this  respect  the  consequences  of  gonorrhoea  were 
trifling. 

Sceligmann  conducted  a  pathologico-anatomical  investigation 
which  led  him  to  conclude  that  in  cases  of  gonorrhoeal  epididymitis, 
in  addition  to  the  inflammation  of  the  epididymis,  phlebitis  and  peri- 
phlebitis  of  the  plexus  pampiniformis  occurs,  and  also  lymphangitis 
of  the  extensive  system  of  lymphatic  vessels  which  pass  through 


536  THE  SEXUAL  LIFE  OF  WOMAN. 

the  spermatic  cord  from  the  testicle;  the  changes  left  in  the  blood 
and  lymphatic  vessels  by  the  inflammation,  result  in  the  testicle  being 
for  the  future  imperfectly  nourished,  and  often  therefore  lead  to  im- 
pairment of  the  functions  of  this  organ;  thus  the  oligospermia  so 
frequently  seen  as  a  sequel  of  gonorrhoeal  epididymitis  (the  ejac- 
ulated semen  containing  but  few  spermatozoa,  and  these  with  little 
or  no  vitality),  is  not  always  due  to  a  complete  obliteration  of  the 
vasa  de.ferentia  by  the  inflammation,  but  in  many  cases  to  the  func- 
tional derangements  of  the  testicle  brought  about  in  the  manner 
above  described.  It  is  probable  also  that  lues  may  give  rise  to 
azoospermia  as  a  result  of  endarteritic  processes.  The  remarkable 
result  of  Sccligmann's  investigations  was  that  in  as  many  as 
75$  of  the  sterile  marriages  that  came  under  his  observation,  the 
husband  was  the  one  to  blame. 

Latterly,  the  view  that  gonorrhoeal  infection  plays  a  very  con- 
siderable part  in  the  etiology  of  sterility  in  women,  has  been  widely 
accepted.  Among  German  gynecologists,  Olshausen,  a  man  of 
enormous  experience,  considers  that  Noggerath's  book,  notwith- 
standing much  exaggeration,  is  substantially  accurate  in  its  main 
conclusions.  A  similar  view  of  Noggerath's  work  is  taken  by  E. 
Schwartz,  Bandl,  A.  Martin,  and  Hofmeier. 

According  to  the  exhaustive  work  of  E.  Sclnvartz,  gonorrhoea  is 
in  women  one  of  the  commonest  causes  of  sterility.  Sterility  due 
to  this  disease  may  be  either  primary  or  secondary.  In  some  cases 
no  ovum  can  find  its  way  into  the  uterus,  either  because  the  ovaries 
are  completely  enveloped  in  masses  of  exudation  and  pseudo-mem- 
branes, or  on  account  of  dislocation  of  the  ovaries  and  the  Fallopian 
tubes,  or  because  the  tubes  have  been  rendered  impermeable  by 
inflammatory  stenosis  or  flexion,  or  by  loss  of  their  ciliated  epithe- 
lium; in  other  cases  the  ovum,  indeed,  enters  the  uterus,  but  fails 
to  be  implanted  upon  the  diseased  mucous  membrane ;  again,  it  is 
conceivable  that  even  when  ovum  and  spermatozoon  are  properly 
formed  and  encounter  one  another  in  the  normal  manner  in  the 
tube  or  in  the  uterine  cavity,  and  when  the  uterine  mucous  mem- 
brane is  in  a  condition  suitable  for  the  implantation  of  the  fertilized 
ovum,  contact  with  gonorrhoeal  secretions  may  have  impaired  the 
vitality  of  the  ovum  or  of  the  spermatozoon,  or  of  both,  to  such  a 
degree,  that  either  fertilization  fails  to  occur,  or  the  fertilized  ovum 
is  incapable  of  further  development.  In  some  instances,  sterility 
dates  from  the  first  infection  of  the  wife ;  but  more  commonly  it 
does  not  develop  until  after  the  completion  of  one  or  more  preg- 
nancies. 

Hofmeier  rightly  points  out  that  \vhilst  gonorrhoeal  infection  in 
women  may  cause  sterility,  such  sterility  is  by  no  means  an  inevit- 
able consequence  of  the  disease. 


THE  SEXUAL  EPOCH  OF  THE  MENACME.  537 

Other  gynecologists  are  even  more  reserved  in  admitting  the 
importance  of  gonorrhoea  as  a  cause  of  sterility  in  women.  Fritsch 
is  of  opinion  that  in  many  cases  a  casual  relation  is  believed  to 
exist,  when  in  reality  there  is  nothing  more  than  a  coincidence. 
Sterility  and  slight  perimetritis,  he  remarks,  are  common  in  women ; 
gonorrhoea  is  common  in  men.  But  it  does  not  follow  that  the 
frequent  gonorrhoea  of  the  husbands  is  the  sole  cause  of  the  fre- 
quent sterility  and  perimetritis  of  the  wives.  "  For  several  years,"  he 
continues,  "  I  have  examined  all  the  men  I  possibly  could  for 
evidence  of  the  existence  of  gonorrhoea,  and  have  enquired  for  a 
history  of  previous  attacks  of  the  disease.  To  my  astonishment 
I  discovered  that  the  fathers  of  many  children,  whose  wives  had 
come  to  consult  me  for  some  quite  disconnected  condition,  had 
quite  as  often  suffered  formerly  from  gonorrhoea  as  the  husbands 
of  sterile  wives." 

M.  Saengcr  is  one  who  very  vigorously  upholds  Noggerath's 
views.  He  insists  that,  excluding  pucllae  publicae  from  considera- 
tion, no  less  than  12$  of  all  gynecological  disorders  depend  upon 
pathological  processes  referable  to  gonorrhoeal  infection  of  the 
female  genital  organs.  To  establish  this  thesis,  it  is  not  necessary 
to  prove  that  Ncisser's  gonococcus  is  or  has  been  present;  the 
diagnosis  must  be  based  principally  upon  clinical  considerations. 
Chronic  vaginitis  and  urethritis,  inflammation  of  the  uterine  mucous 
membrane,  tubal  suppuration,  oophoritis,  and  perimetritic  adhesions 
(especially  those  which  unite  all  the  lateral  pelvic  organs  into  a 
shapeless  knot) — these  are  conditions  thoroughly  characteristic  of 
gonorrhoea. 

No  less  unfavourable  an  influence  of  gonorrhoeal  infection  upon 
fertility  is  shown  by  the  observations  of  Gliinder.  Women  num- 
bering 87  were  in  attendance  at  the  gynecological  department  of  the 
Policlinik  of  the  University  of  Berlin,  all  of  them  seeking  advice 
on  account  of  sterility.  In  the  case  of  24  of  these,  the  husband 
was  also  present;  19  of  these  men  admitted  having  previously 
suffered  from  gonorrhoea ;  the  remaining  5  denied  such  infection, 
although  the  wives  of  all  of  these  had  symptoms  pointing  unmis- 
takably to  gonorrhoeal  infection ;  among  the  other  63  women,  there 
were  8  only  in  whom  the  genital  organs  were  found  perfectly 
normal,  whilst  in  38  of  them  there  were  signs  of  previous  gon- 
orrhoeal infection.  Thus  we  see  that  of  these  87  sterile  women, 
62  (71.3^)  had  had  gonorrhoea;  and  Gliinder,  assuming  that  in 
these  cases  the  gonorrhoea  was  the  efficient  cause  of  the  sterility, 
and  regarding  the  average  percentage  of  sterile  marriages  as  12.34 
in  every  100  contracted,  is  led  to  the  conclusion  that  of  every  eleven 
or  twelve  marriages,  one  is  rendered  sterile  in  consequence  of 
gonorrhoea. 


538  THE  SEXUAL  LIFE  OF  WOMAN. 

To  the  same  opinion,  that  gonorrhoea  is  the  principal  cause  of 
sterility,  Lier  and  Ascher  were  led  by  an  investigation  of  numerous 
clinical  histories.  Moreover,  they  believe  that  in  the  large  majority 
of  sterile  marriages,  the  husband  is  directly  or  indirectly  responsible. 
Directly,  in  so  far  as  a  very  large  percentage  of  men  have  their 
reproductive  capacity  annihilated  by  gonorrhoea;  indirectly,  be- 
cause, of  those  who  retain  their  fertilizing  powers,  so  large  a 
number  infect  their  wives  with  gonorrhoea,  and  thus  render  them 
incapable  of  conceiving,  that  chronic  gonorrhoea —  in  the  female 
harder  to  eradicate  even  than  in  the  male  —  must  be  regarded  as 
the  arch-enemy  of  fertility.  Of  80  men  affected  with  azoospermia, 
all  cases  observed  by  Prochownik,  in  75  the  disease  was  the  sequel 
of  gonorrhoea ;  of  the  remaining  5  cases,  two  were  due  to  syphilitic 
disease  of  the  testicles,  one  to  tubercular  disease  of  the  same,  whilst 
two  were  due  to  long  continued  masturbation,  with  consecutive 
atrophy  of  the  testis  and  epididymis. 

But  that  the  obstacle  offered  to  conception  by  gonorrhoeal  infec- 
tion is  by  no  means  so  powerful  as  Noggerath  and  his  supporters 
believed,  is  shown  by  the  investigations  of  Oppenheimer,  who,  in 
Kchrer's  clinique  at  Heidelberg,  examined  108  pregnant  women  for 
the  presence  of  gonococci,  and  found  these  organisms,  pathognomonic 
of  gonorrhoeal  infection,  in  no  less  than  30  of  them,  that  is,  in  27.7^. 
Thus,  in  this  large  number  of  cases,  pregnancy  had  occurred  not- 
withstanding the  presence  of  gonorrhoea.  Loiter,  again,  in 
Schrocder's  clinique,  examined  32  patients  during  the  lying-in  period, 
and  detected  the  presence  of  gonococci  in  26;  an  experience  which 
also  proves  that  gonorrhoeal  infection  is  no  bar  to  pregnancy.  Dun- 
stone  has  recently  recorded  5  cases  in  which,  notwithstanding  the 
existence  of  gonorrhoea,  the  women  became  pregnant  once  or  several 
times. 

In  the  "  Medical  Brief  "  the  question  was  mooted,  "  Can  a  woman 
have  children  subsequently  to  being  infected  with  gonorrhoea?" 
Numerous  affirmative  answers  were  received ;  and  among  them  one 
mentioning  the  case  of  a  woman  who  was  infected  with  gonorrhoea 
at  the  age  of  18,  and  subsequently  gave  birth  to  8  children. 

The  question  of  sterility  in  prostitutes  has  also  attracted  atten- 
tion, since  these  women  may  be  regarded  as  invariably  infected 
with  gonorrhoea.  Meissncr  and  Jcanncl  speak  of  the  infertility 
of  prostitutes  as  a  well-known  fact;  and  the  latter  states  that, 
whereas,  according  to  Montesquieu,  to  every  100  women  in  France, 
on  an  average  341  children  are  born,  of  which  200  grow  up,  to  100 
prostitutes  in  Bordeaux  there  were  born  60  children  only,  and  of 
these  but  21  attained  maturity.  Marc  d'Espine  affirms  that  among 
2,000  prostitutes  not  more  than  two  or  three  will  have  children  in  a 
year.  Parent-Duchatelct,  on  the  other  hand,  regards  the  sterility  of 


THE  SEXUAL  EPOCH  OF  THE  MENAGME.  539 

these  women  as  a  purely  temporary  affair,  and  writes :  "  les  prosti- 
tuees  congoivent  souvent,  mais  elles  avortment  f requement  j"1  and 
this  frequency  of  abortion  he  attributes  to  two  causes,  in  the  first 
place  to  deliberate  induction  of  abortion,  and  in  the  second  place,  to 
their  mode  of  life.  He  continues :  "  cette  fecondite  a  lieu  surtout 
lorsque,  quittant  leur  mettier,  elles  se  marient  ou  s'attachent  a  un  seul 
homme ;  dans  ce  cas  les  grossesses  se  succedent,  elles  sont  toujours 
heureuses  et  les  infants  qui  en  proviennent  sout  aussi  vivaces  que  les 
autres ;"  2  thus,  in  his  opinion  the  sterility  of  prostitutes  lasts  only 
as  long  as  they  pursue  their  occupation. 

The  question  as  to  what  influence,  if  any,  gonorrhoeal  secretion 
has  per  se  upon  the  semen,  has  often  been  asked,  but  not  yet  satis- 
factorily answered.  We  have  no  certain  knowledge  whether  the 
gonococci,  the  pus  cells,  or  one  of  the  toxins  of  the  secretion,  exer- 
cises a  deleterious  influence  upon  the  vitality  of  the  spermatozoa; 
it  is  certainly  possible  that  this  may  be  the  case,  for  the  diplococci, 
just  as  much  as  streptococci  and  staphylococci,  are  found  not  only 
within  the  cells,  but  also  in  the  intercellular  fluid  and  in  the  detritus, 
and  so  must  be  brought  into  intimate  contact  with  the  spermatozoa ; 
but  inasmuch  as  quite  a  number  of  persons  who  are  at  the  time 
actually  suffering  from  gonorrhoea  beget  children,  we  are  com- 
pelled to  assume  that  for  the  harmful  influence,  if  any  such  exists, 
to  be  exercised,  a  prolonged  contact  of  the  semen  with  the  gon- 
orrhoeal pus  is  necessary.  In  cases  of  gonorrhoeal  epididymitis  and 
prostatitis,  and  also  in  gonorrhoeal  urethritis,  no  such  prolonged  con- 
tact occurs ;  but  when  the  vas  deferens  or  the  vesicula  seminalis  is 
inflamed,  the  contact  is  more  prolonged,  and  may  suffice  to  destroy 
the  vitality  of  the  spermatozoa,  which  are  extremely  sensitive  to 
chemical  stimuli.  In  8  cases  observed  by  Kroner,  the  fruitful  coitus 
was  unquestionably  effected  when  the  husband  was  suffering  from 
.still  active  gonorrhoea ;  in  all  the  cases  the  children  were  born 
at  full  term,  and  all  suffered  from  conjuctival  blenorrhoea.  That 
gonorrhoea  often  fails  to  induce  sterility,  is  shown  by  the  familiar 
fact  that  a  woman  frequently  has  one  child  after  another,  all  infected 
with  this  conjunctival  form  of  gonorrhoea,  showing  that  the  mother 
remains  fertile  notwithstanding  the  persistency  of  the  gonorrhoeal 
infection. 

Upon  the  investigation  of  60  carefully  written  clinical  histories, 
dealing  with  the  relation  between  proved  gonorrhoeal  infection  and 
a  sterile  marriage,  Grechen  has  drawn  up  the  following  table, 

1  "  Prostitutes  conceive  often,  but  abort  frequently." 

2  "  Prostitutes    become    fecund    when,    abandoning    their    profession,    they 
marry,   or  pass   under  the  protection  of  a  single    man ;   in  such   cases  they 
become  pregnant,  they  are  always  happy,  and  their  children  are  as  healthy  as 
those  of  other  women." 


540  THE  SEXUAL  LIFE  OF  WOMAN. 

showing  the  various  ways  in  which  chronic  gonorrhoea  may  give 
rise  to  sterility : 

A.  Absolute  Sterility. 

a.  Owing  to  impossibility  of  fertilization,  in  consequence  of  de- 
fective formation  of  spermatozoon  or  ovum: 

I.  In  the  male : 

1.  Aspermatism. 

2.  Azoospermia. 
.  II.  In  the  female: 

Oophoritis  glandularis. 

b.  Owing  to   impossibility   of   pregnancy,   although   semen   and 
ovum  may  be  normal,  and  fertilization  can  be  effected : 

Gonorrhoeal  endometritis  of  atrophic  character. 

B.  Relative  Sterility. 

a.  Owing  to   mechanical   interference   with   the  conjugation   of 
spermatozoon  and  ovum: 

I.  In  the  male : 

1.  Epididymitis  duplex. 

2.  Strictura  impermeabilis  urethae. 
II.  In  the  female : 

I.  Perioophoritis    and    perimetritis,    and    their    results,    viz., 

adhesions  and  displacements  of  the  reproductive  organs. 
2.  Tubal   catarrh,   pyosalpinx,   kinking  and   other    forms   of 
obstruction  of  the  tubes. 

b.  Owing  to  extension  of  the  gonorrhoeal  process  to  the  decidua, 
causing  abortion  in  the  early  period  of  pregnancy: 

Endometritis  gonorrhoeica'  chronica,  and  endometritis  decidualis. 

Bender  has  endeavoured  to  elucidate  the  problem  of  the  relations 
between  gonorrhoea  and  sterility  by  a  collective  investigation  in  the 
army.  The  investigation  was  concerned  with  474  men  who  during 
their  period  of  service  with  the  colours  had  been  treated  for  gon- 
orrhoea, and  who  subsequently  had  married.  Dealing  with  all  cases 
alike,  without  regard  to  complications  which  had  been  observed  in 
some  cases  but  not  in  others,  of  the  474  wives,  there  were  64  who 
never  became  pregnant  =  13.5^ ;  78  who  had  one  child  only  =  16.5^ ; 
total,  142  =  30^. 

Leaving  out  of  consideration  the  cases  in  which  epididymitis  had 
been  observed,  there  remained  363  cases  of  uncomplicated  urethritis ; 
of  the  363  wives  of  these  men,  there  were  38  who  never  became 
pregnant  =  10.5^;  63  who  had  one  child  only  =  17.3^;  total  101 
=  27.8,*. 

Thus,  in  the  cases  in  which  the  husbands  had  had  uncomplicated 
urethritis,  the  percentage  of  absolute  sterility  was  only  10.5 ;  while 


THE  SEXUAL  EPOCH  OF  THE  MENACME.  541 

in  the  unselected  cases  of  gonorrhoea,  it  was  no  more  than  13.5. 
The  figures  show  clearly  that  the  influence  of  uncomplicated  gon- 
orrhoea is  but  trifling;  indeed,  it  is  obvious  that  this  must  be  the 
case,  for  it  is  probable  that  not  less  than  80^  of  men  experience  at 
least  one  attack  of  gonorrhoea,  and  did  this  give  rise  to  sterility, 
either  directly  by  its  influence  on  the  men  themselves,  or  indirectly 
by  transmission  to  their  wives,  the  human  race  would  soon  die  out. 
Moreover,  the  frequent  occurrence  of  ophthalmia  neonatorum  is  a 
sufficient  proof  that  notwithstanding  gonorrhoeaf  infection  in  all 
these  cases,  pregnancy  and  delivery  have  taken  place. 

To  sum  up,  it  is  my  opinion  that  in  recent  years  the  influence 
of  gonorrhoeal  infection  in  inducing  sterility  in  women  has  been 
painted  in  far  too  gloomy  colours,  and  it  is  time  that  these  extreme 
views  should  be  abandoned. 

This  is  a  convenient  place  to  insist  upon  the  fact  that  in  cases 
which  are  by  no  means  rare,  in  the  absence  of  aspermatism  and 
azoospermia,  and  altogether  independently  of  gonorrhoeal  infection, 
it  is  the  husband  who  is  responsible  for  the  occurrence  of  sterility ; 
in  such  cases  the  sterility  is  due  to  failure  of  conjugation  between 
spermatozoon  and  ovum,  dependent  upon  congenital  or  acquired 
defects  of  the  penis.  The  great  majority  of  cases  of  this  kind  are 
due  to  hypospadias. 

A  case  of  sterile  marriage  is  reported  by  Licr  and  Ascher,  in 
which  the  husband  had  suffered  from  hyspospadias  and  had  been 
operated  upon  for  the  relief  of  that  condition.  Although  erection 
of  the  penis  was  normal,  and  coitus  terminated  in  the  usual  orgasm, 
with  sense  of  ejaculation,  the  semen  did  not  find  its  way  into  the 
vagina;  it  accumulated  in  the  artificial  cul-de-lac  between  the  for- 
mer abnormal  urethral  orifice  and  the  artificially  constructed  meatus, 
and  after  coitus  the  semen  had  to  be  expelled  from  this  region  by 
digital  pressure. 

Mtclucho-Mackay  reports  that  among  the  Australian  aborigines, 
hypospadias  is  artificially  induced,  in  order  to  prevent  fertilization. 
In  young  boys,  an  incision  is  made  through  the  lower  wall  of  the 
urethra  from  the  meatus  as  far  up  as  the  scrotum,  and  care  is  taken 
that  the  several  surfaces  do  not  reunite.  During  coitus,  the  semen 
flows  away  without  entering  the  vagina.  This  mutilation  is  prac- 
tised, not  only  in  South  and  Central  Australia,  but  also  by  the 
indigens  of  Port  Darwin. 

That  hypospadias  does  not  in  all  cases  offer  an  insuperable  obstacle 
to  impregnation,  is,  however,*  shown  by  a  striking  case  which  came 
under  the  notice  of  Labalbary.  He  saw  a  hypospadiac  who,  in 
micturating,  had  to  crouch  down  in  the  feminine  posture,  because 
he  was  unable  to  project  the  stream  of  urine  forwards ;  in  coitus, 
he  deposited  his  semen  only  on  his  wife's  vulva.  But  his  wife  gave 


542  THE  SEXUAL  LIFE  OF 

birth  to  two  sons,  about  whose  paternity  there  could  be  no  reason- 
able doubt,  since  both  exhibited  the  same  malformation  as  their 
putative  father. 

Occasionally,  phimosis  offers  an  obstacle  to  impregnation,  and 
only  after  relief  of  the  condition  by  operation,  is  the  wish  for 
offspring  fulfilled.  A  case  of  this  nature  is  recorded  by  Amussat. 

In  cases  of  severe  stricture  of  the  urethra,  sterility  may  result, 
although  the  constitution  of  the  semen  is  perfectly  normal.  During 
erection  of  the  penis,  the  stricture  is  completely  closed,  and  the 
semen  accumulates  in  the  urethra  above  it ;  when  the  penis  becomes 
flaccid,  the  semen  flows  away,  outside  the  vagina.  In  some  such  cases, 
the  semen  regurgitates  into  the  bladder,  and  is  not  discharged  until 
the  patient  makes  water.  Although  the  supposition  is  not  one  in 
which  strict  proof  is  obtainable,  it  is  probable  that  the  man  is  at 
fault  in  cases  in  which  the  wives  of  two  or  more  brothers  fail  to 
conceive.  I  have  seen  several  instances  of  the  kind.  Three  brothers, 
all  quite  healthy,  and  of  virile  aspect,  were  married  to  women  in 
whom  on  gynecological  examination  no  significant  abnormality 
could  be  detected ;  they  had  been  married  respectively  for  14,  9,  and 
8  years ;  all  were  childless.  Three  brothers,  two  of  whom  were 
practising  physicians,  had  lived  a  number  of  years  (20,  4,  and  14, 
respectively)  in  sterile  wedlock;  one  of  them  (a  physician)  informed 
me  that  he  ejaculated  always  a  very  small  quantity  of  semen,  and 
thought  it  possible  that  this  was  the  cause  of  the  sterility.  Of  four 
brothers,  two  had  lived  long  in  barren  wedlock;  the  third  had  no 
child  for  14  years  after  marriage,  when  at  last  his  wife  became 
pregnant  after  a  visit  to  a  spa;  the  fourth  brother  is  a  misogynist 
and  a  confirmed  bachelor. 


Sexual  Sensibility  in  Women. 

In  our  consideration  of  the  various  influences  by  which  the  con- 
tact of  ovum  and  spermatozoon  may  be  prevented,  the  degree  of 
sexual  excitement  experienced  by  the  woman  during  the  sexual 
act  must  not  be  overlooked,  for  this  plays  a  part  not  to  be  under- 
estimated, even  though  it  is  a  matter  on  which  it  is  difficult  to 
obtain  accurate  information. 

It  is  extremely  probable  that  an  active  participation  on  the 
part  of  the  woman  in  coitus  has  an  important  influence  upon  the 
attainment  of  fertilization,  i.  e.,  that  sexual  excitement  in  the  woman 
is  a  link  in  the  chain  of  conditions  leading  to  conception.  This 
excitement  has  a  reflex  influence,  but  the  influence  may  be  exercised 
in  either  (or  both)  of  two  ways:  first,  it  may  cause  certain  reflex 
changes  in  the  cervical  secretion,  whereby  the  passage  of  the  sperma- 
tozoa is  facilitated;  or,  secondly,  it  may  give  rise  to  reflex  changes 


THE  SEXUAL  EPOCH  OF  THE  MENACME.  543 

in  the  vaginal  portion  of  the  cervix,  to  a  rounding  of  the  os  uteri 
externum  and  a  hardening  of  the  consistency  of  the  cervix  (changes 
of  an  erectile  nature)  coupled  with  a  slight  descent  of  the  uterus  — 
changes  which  likewise  favour  the  entrance  of  the  semen  into  the 
uterine  cavity.  Theopold  goes  so  far  as  to  say  that  it  is  only 
women  who  experience  erotic  excitement  who  are  capable  of  being 
impregnated. 

My  own  opinion  is  that  considerable  importance  is  to  be  attached 
to  voluptuous  excitement  of  the  woman  during  coitus,  for  the  for- 
mer of  the  two  reasons  mentioned  above,  namely,  because  such 
excitement  leads  to  the  occurrence  of  reflex  secretion  of  the  cervical 
glands,  the  secretion  thus  produced  maintaining  or  enhancing  the 
activity  of  the  spermatozoa ;  and  contrariwise,  in  the  absence  of 
voluptuous  excitement  on  the  woman's  part  there  is  a  failure  of  the 
reflex  secretion,  and  the  passage  of  the  spermatozoa  into  the  uterine 
cavity  is  consequently  less  easily  effected.  That  sexual  excitement 
has  great  influence  upon  the  production  of  the  first  appearance  of 
menstruation,  has  frequently  been  shown ;  and  an  analogy  between 
such  an  influence  and  the  suggested  effect  of  sexual  excitement  in 
favouring  the  occurrence  of  conception,  must  not  lightly  be  rejected. 
It  is  well  known  that  the  first  menstruation  occurs  at  an  earlier 
age  in  girls  living  in  towns  than  in  those  living  in  the  country; 
not  solely  (if  at  all)  in  consequence  of  the  better  nutriment  and 
easier  life  of  the  former,  but  also,  unquestionably,  owing  to  nervous 
influences.  It  is,  moreover,  a  familiar  experience  that  factory  girls, 
who  from  early  youth  are  exposed  to  sexual  stimulation,  attain 
sexual  maturity  at  an  extremely  early  age.  Again,  from  early 
times  it  has  been  the  prevailing  opinion  of  the  common  people 
that  for  the  impregnation  of  a  woman  it  was  necessary  -for  her  to 
experience  voluptuous  excitement,  or  at  least,  that  in  the  absence 
of  such  excitement,  conception  was  rendered  difficult.  Riedel  re- 
lates of  the  indigens  of  the  Island  of  Buru,  that  they  often  have 
sexual  intercourse  with  foreigners,  "  but  during  such  intercourse 
they  remain  quite  passive,  in  order  to  avoid  impregnation."  It  is 
not  an  unusual  experience  in  gynecological  practice  for  a  sterile 
woman,  in  the  absence  of  any  prompting,  to  complain  that  during 
coitus  she  has  no  "  feeling  "  whatever,  and  to  attribute  to  this  lack 
of  feeling  her  failure  to  conceive. 

A  cultured  lady,  the  mother  of  several  children,  assured  me,  not 
only  that  she  was  always  aware,  whether  an  act  of  intercourse  would 
or  would  not  lead  to  impregnation,  but  further,  that  it  was  within 
her  power  to  determine  whether  the  intercourse  should  or  should 
not  be  fruitful.  If  she  was  passive  during  intercourse,  or  if,  to 
use  her  own  expression,  her  attitude  was  one  of  "  laisser  faire, 
laisser  aller,"  conception  would  not  occur;  but  if,  on  the  other 


544  THE  SEXUAL  LIFE  OF  WOMAN. 

i 

liand,  she  took  an  active  part  in  the  coitus,  so  that  she  experienced 
a  powerful  voluptuous  sensation,  pregnancy  would  result  from  the 
intercourse. 

In  some  cases,  the  previously  described  condition  of  dyspareunia 
is  the  cause  of  the  sterility.  In  fact,  the  combination  of  dyspareunia 
with  sterility  is  so  strikingly  common,  that  my  own  observations 
have  led  me  to  infer  that  there  is  a  casual  connexion  between  the 
two  states,  at  least  in  a  considerable  proportion  of  cases. 

I  append  a  short  note  of  a  few  instances  of  this  kind:  Mrs.  G., 
aged  27,  married  6  years,  sterile ;  an  anaemic,  delicate  lady,  who  has 
never  experienced  the  sense  of  ejaculation.  The  semen  flows  away 
from  the  vagina  immediately  after  the  completion  of  coitus.  No 
abnormality  to  be  detected  on  gynecological  examination.  Mrs.  S., 
aged  24,  married  5  years,  sterile ;  during  intercourse  remains  com- 
pletely cold,  and  has  experienced  the  sense  of  ejaculation  in  dreams 
only.  Gynecological  examination  disclosed  the  existence  of  slight 
cervical  catarrh,  but  no  other  abnormality.  Mrs.  E.,  aged  30, 
married  10  years,  had  a  child  9  years  previously,  a  difficult  delivery 
followed  by  puerperal  disease,  since  then  sterile ;  she  states  that 
since  her  delivery  she  has  not  experienced  the  sense  of  ejaculation, 
with  which  she  was  formerly  familiar;  further,  since  that  time  she 
has  suffered  from  profluvium  seminis.  On  gynecological  examina- 
tion the  uterus  was  found  to  be  enlarged  and  retroflexed.  Mrs.  K., 
aged  28,  married  6  years,  sterile ;  amenorrhoeic,  has  never  experi- 
enced the  sense  of  ejaculation,  and  finds  sexual  intercourse  so  un- 
pleasant that,  "  in  order  to  be  left  in  peace,"  she  has  herself  begged 
her  husband  to  keep  a  mistress.  Examination  showed  the  uterus  to 
be  in  an  infantile  condition. 

Whilst  I  have  notes  of  numerous  cases  similar  to  those  just  quoted, 
I  must  also  insist  upon  the  fact  that  I  have  sometimes  had  com- 
plaints of  dyspareunia  from  wives  whose  fertility  has  been  proved 
by  the  birth  of  numerous  children.  And,  again,  anyone  whose 
position  permits  him  frequent  glimpses  of  what  passes  behind  the 
scenes  of  married  life,  will  from  time  to  time  have  noticed  as  signs 
of  relative  dyspareunia  instances  in  which  the  faithless  wife  is  far 
more  readily  impregnated  by  her  lover  than  by  the  husband  to 
whom  she  is  indifferent  or  whom  she  actually  dislikes. 

To  relative  dyspareunia  dependent  upon  sexual  dysharmony  we 
must  refer  also  those  instances  in  which  a  man  and  a  woman  prove 
sterile  while  living  together  for  a  considerable  period  as  man  and 
wife,  but  after  separation  both  prove  fertile  in  fresh  unions.  Several 
such  cases  have  come  within  my  own  experience,  and  similar  in- 
stances attracted  the  attention  of  the  observers  of  antiquity  —  Aris- 
totle, for  example.  Hallcr,  for  this  reason,  lays  stress  on  the  lack 


THE  SEXUAL  EPOCH  OF  THE  MENACME.  545 

of  mutual  affection  as  a  cause  of  sterility;  and  Virey,  also,  believes 
that  sterility  may  often  depend  upon  the  absence  of  the  "  harmonic 
d'amour." 

It  is  possible  that  the  custom,  which  in  certain  rural  districts  has 
persisted  into  quite  recent  times,  of  a  temporary  experimental  co- 
habitation of  candidates  for  matrimony,  was  based  on  an  attempt 
to  discover  the  existence  of  such  a  sexual  harmony.  Ploss,  for 
instance,  reports  that  in  East  Prussia,  in  1864,  he  was  informed  that 
among  the  Mazurs  this  custom  of  an  experimental  year  of  cohabi- 
tation was  in  force.  If  during  this  year  the  woman  became  preg- 
nant, the  young  couple  were  married ;  but  if  pregnancy  failed  to 
occur,  they  separated,  considering  they  were  not  formed  for  one 
another. 

A  well-known  historical  example  of  relative  sterility  is  furnished 
by  the  two  marriages  of  Napoleon  I.  His  first  marriage  to  Jose- 
phine remained  sterile,  though  Josephine  had  children  by  Beau- 
harnais ;  and  Napoleon,  remarried  to  Marie  Louise,  had  a  son  by 
the  latter. 

Von  Gutceit,  a  physician  of  wide  experience,  points  out  that 
"  sensitive  women,  who  have  a  mental  or  physical  antipathy  to  co- 
habitation, or  who  have  a  secret  but  ardent  affection  for  some 
other  man,  often  fail  to  conceive  as  a  result  of  intercourse  with 
their  husbands ;  but  when,  in  illicit  intercourse,  they  experience  the 
voluptuous  sensations  to  which  they  have  hitherto  been  strangers, 
pregnancy  often  speedily  ensues."  He  maintains,  further,  that  such 
women,  in  consequence  of  the  stimulation  of  the  genital  organs  in 
the  absence  of  sexual  gratification,  become  affected  with  all  kinds 
of  menstrual  irregularities,  with  fluor  albus,  prolapse  of  the  uterus, 
and  chronic  metritis;  they  suffer  from  digestive  disturbances  and 
constipation,  leading  to  emaciation ;  and  they  are  prone  to  hysterical 
manifestations." 

Analogous  phenomena  have  been  noted,  and  with  much  greater 
distinctness,  in  the  animal  world.  Darwin,  writing  on  this  subject, 
remarks :  "  It  is  by  no  means  a  rare  occurrence,  that  certain  males 
and  females  will  not  be  fruitful  in  intercourse  together,  whilst  the 
same  individuals  prove  perfectly  fertile  in  intercourse  with  other 
members  of  their  species  —  and  this  in  cases  in  which  there  is  no 
evidence  that  the  subsequent  fertility  is  due  to  any  change  in  the 
conditions  of  life.  The  cause  is  probably  to  be  found  in  an  innate 
sexual  dysharmony  between  the  infertile  pair.  A  very  large  num- 
ber of  instances  of  this  kind  have  been  reported  to  me  by  well- 
known  breeders  of  horses,  cattle,  pigs,  dogs,  and  pigeons.  Some- 
times a  breeder  will  fail  to  obtain  offspring  from  a  male  and  a 
female  of  known  fertility  whom  he  wishes  to  couple  for  some  special 
reasons.  The  most  celebrated  living  horse-breeder  informed  me 

35 


546  THE  SEXUAL  LIFE  OF  WOMAN. 

that  frequently  a  mare,  which  in  other  seasons  with  other  stallions 
has  proved  fertile,  may  be  coupled  with  a  stallion  likewise  of  proved 
reproductive  potency,  and  will  fail  to  be  impregnated ;  yet  this  same 
mare  will  shortly  afterwards  be  impregnated  by  another  stallion." 

PHuger  reports  that  he  has  often  seen  a  thoroughbred  stallion, 
which  was  fully  prepared,  at  a  moment's  notice,  to  serve  a  thorough- 
bred mare,  prove  extremely  unwilling  to  serve  a  common  mare  on 
heat,  and  only  induced  to  do  so  with  the  greatest  difficulty,  and  in- 
deed by  a  trick.  The  stallion  is  placed  in  the  central  one  of  three 
stalls,  on  one  side  of  him  is  the  thoroughbred  mare,  whilst  in  the 
third  stall  is  the  common  mare,  covered  with  a  cloth.  The  stallion's 
head  is  turned  to  show  him  the  thoroughbred  mare ;  immediately  his 
appearance  undergoes  a  change.  Every  muscle  of  his  body  appears 
to  quiver,  and  never  does  a  fine  animal  appear  more  beautiful  than 
at  such  a  moment,  full  of  pride,  fire,  and  vitality.1  As  soon  as 
the  stallion  makes  ready  to  serve  the  mare,  he  is  rapidly  led  to  the 
other  stall,  and  suitably  assisted  to  the  actual  commencement  of 
intercourse  with  the  substituted  mare.  But  it  sometimes  happens,  as 
PHuger  himself  has  seen,  that  the  stallion  becoming  aware  of  the 
deception,  refuses  to  complete  the  coitus,  withdraws  his  penis, 
and  immediately  turns  to  the  mare  of  his  choice. 

Matthews  Duncan,  among  191  sterile  women,  found  that  39  had 
no  sexual  appetite,  and  62  had  no  voluptuous  sensations  during 
coitus.  He  regards  abnormal  sexual  appetite  as  one  of  the  principal 
causes  of  sterility. 

Notwithstanding  these  facts,  it  must  not  be  forgotten  that  many 
cases  are  recorded  in  medical  literature  of  women  conceiving  after 
intercourse  effected  against  their  wishes,  as  by  rape,  or  when  they 
were  in  a  state  of  intoxication,  or  asleep,  or  in  the  entire  absence  of 
all  voluptuous  sensation.  Moreover,  the  erection  of  the  vaginal 
portion  of  the  cervix,  and  the  reflex  movements  and  secretory 
changes  in  the  uterus,  may  also  occur  independently  of  sexual 
desire  and  voluptuous  sensation ;  but  such  cases  are  certainly  excep- 
tional, and  their  credibility  is  frequently  open  to  suspicion.  In 

1  Compare  stanzas  46  and  47  of  "  Venus  and  Adonis  " : 

His  ears  up-prick'd ;  his  braided  hanging  mane 

Upon  his  compass'd  crest  now  stands  on  end; 

His  nostrils  drink  the  air,  and  forth  again, 

As  from  a  furnace,  vapours  does  he  send : 

His  eye,  which  scornfully  glisters  like  fire, 
Shows  his  hot  courage  and  his  high  desire. 

Sometimes  he  trots,  as  if  he  told  the  steps, 

With  gentle  majesty  and  modest  pride; 

Anon  he  rears  upright,  curvets  and  leaps, 

As  who  should  say,  "  Lo !  thus  my  strength  is  tried; 
And  this  I  do  to  captivate  the  eye 
Of  the  fair  breeder  that  is  standing  by." 


THE  SEXUAL  Erocn  OF  THE  MENACME.  547 

numerous  instances  in  which  conception  is  stated  to  have  followed 
intercourse  in  a  state  of  unconsciousness,  judicial  proceedings  have 
elicited  the  fact  that  the  intercourse  was  not  entirely  involuntary 
on  the  woman's  part,  and  that  the  alleged  force  was  no  more  than 
a  vis  grata.  Von  Maschka  reports  a  case  in  which  a  girl  asserted 
that  she  had  been  violated  whilst  in  a  condition  of  epileptic  uncon- 
sciousness, but  she  remembered  every  detail  of  the  act  with  pre- 
cision. Casper,  again,  in  a  case  in  which  it  was  asserted  that  de- 
floration had  been  forcibly  effected  whilst  the  girl  was  in  a  state  of 
alcoholic  coma,  showed  that  there  had  been  no  more  than  moderate 
intoxication  combined  with  great  sexual  excitement.  Assertions 
that  pregnancy  has  resulted  from  intercourse  effected  during  sleep, 
in  a  state  of  unconsciousness,  or  in  the  "  magnetic  "  or  "  hypnotic  " 
state,  should  always  be  accepted  with  reserve. 

It  is  interesting  to  note  in  this  connexion  that  the  Chinese  physi- 
cians enumerates  among  the  causes  of  sterility  the  practice  of 
"congfou"  by  the  man,  this  name  being  given  to  a  manipulation 
analogous  to  hypnotism,  whereby  the  voluptuous  sensation  during 
intercourse  is  diminished  or  abolished  by  distracting  the  attention 
elsewhere. 

A  proof  of  the  importance  of  specific  sexual  sensation  for  the 
attainment  of  conception  is  afforded  by  the  fact  that  in  the  majority 
of  women  voluptuous  excitement  is  absent  at  the  first  act  of  inter- 
course, and  only  gradually  develops  thereafter;  in  correspondence 
with  this,  we  find  that  the  first  conception  does  not  usually  occur 
until  some  time  after  marriage,  and  that  the  period  of  its  occurrence 
frequently  coincides  with  the  full  development  of  voluptuous  sensa- 
tion during  intercourse.  Thus,  even  in  the  woman  fully  fitted  for 
conception,  the  actual  capacity  for  impregnation  is  only  developed 
gradually,  and  after  a  sufficient  Experience  of  intercourse. 

This  transient  incapacity  for  conception  may,  indeed,  also  depend 
upon  the  fact  that  at  first  coitus  is  apt  to  be  incompletely  effected, 
and  for  this  both  husband  and  wife  are  to  blame  ;  but  unquestionably 
in  many  cases  the  reason  is  the  one  first  mentioned. 

In  some  cases,  certain  psychical  influences  which  affect  the  in- 
tensity of  the  voluptuous  sensation,  manifest  its  significance.  Thus, 
in  some  instances,  the  influence  of  stimulation  of  the  clitoris  in  lead- 
ing to  conception  has  been  clearly  shown ;  in  others,  the  performance 
of  coitus  in  some  unusual  position,  varying  with  the  woman  con- 
cerned, is  alone  competent  to  arouse  sexual  sensibility  to  its  full 
extent,  and  to  bring  about  the  orgasm.  One  occasionally  receives 
confidential  information  from  a  husband  that  his  wife  experiences 
a  voluptuous  sensation  only  when  coitus  is  performed  in  the  lateral 
posture,  or  more  bestiarum,  or  in  the  situs  inversus,  etc.,  etc. 


548  THE  SEXUAL  LIFE  OF  WOMAN. 

Excessive  frequency  of  intercourse,  prolonged  and  repeated  sexual 
excitement,  on  the  other  hand,  induce  sterility,  as  is  well  seen  in 
prostitutes,  who  rarely  become  pregnant. 

Finally,  perverse  sexual  impulse  must  be  mentioned  as  a  possible 
cause  of  sterility.  This  may  be  an  acquired  perversion,  due  to  the 
fact  that  at  the  epoch  of  the  menarche,  the  commencement  of 
puberty,  owing  to  the  strength  of  sexual  desire  whilst  intercourse 
is  an  impossibility,  or  simply  from  evil  example,  the  girl  has  become 
a  confirmed  onanist,  and  continues  the  habit  even  after  marriage. 
In  other  cases  we  have  to  do  with  a  psychopathic  state,  a  form  of 
mental  degeneration  due  to  very  various  causes,  or  in  some  cases 
inverted  sexual  sensibility  exists  in  a  person  whose  mind  is  in  other 
respects  normal.  In  women  with  sexual  inversion,  ordinary  copu- 
lation with  the  male  is  insufficient  to  arouse  the  sexual  orgasm, 
and  for  this  reason,  as  well  as  because  persons  thus  affected  avoid 
coitus  as  much  as  possible,  sterility  commonly  ensues. 

In  sterile  homosexual  women,  and  equally  so  in  women  addicted 
to  masturbation,  gynecological  examination  may  disclose  no  abnor- 
mality whatever ;  but  in  -other  cases  of  the  kind  we  may  find  a  con- 
tributory cause  of  sterility  in  the  fact  that  the  internal  genital 
organs  are  imperfectly  developed,  or  even  completely  absent.  In 
sterile  women,  if  on  gynecological  examination  we  find  certain 
characteristic  changes  in  the  reproductive  organs,  a  strong  suspicion 
will  be  aroused  that  the  sterility  is  due  to  abnormal  modes  of  sexual 
gratification.  The  changes  in  question  are :  hypertrophy  of  the 
clitoris,  enlargement  and  a  bluish  colouration  of  the  labia  minora, 
retroversion  of  the  uterus,  neuralgia  and  displacement  of  the  ovaries, 
leucerrhoea,  and  menorrhagia. 

The  question  has  been  mooted  by  Cohnstein,  whether,  as  is  com- 
monly assumed,  a  woman  is  capable  of  becoming  pregnant  at  any 
time  during  the  year,  or  whether,  as  in  the  lower  animals,  the  re- 
productive capacity  can  be  exercised  only  at  certain  seasons,  or 
again,  whether  there  may  not  be  individual  moments  of 'predilection 
for  the  occurrence  of  conception.  He  found  that  in  the  great 
majority  of  women  there  were  .such  seasons  of  predilection,  and 
only  in  a  minority  could  conception  be  effected  indifferently  at  any 
time  of  the  year.  As  a  proof  of  this  assertion,  he  appends  the  fol- 
lowing case:  A  married  woman,  33  years  of  age,  had  several 
years  before  been  delivered  prematurely  of  a  stillborn  child,  and 
since  then  had  not  again  been  pregnant.  Her  reproductive  organs 
were  normal.  The  husband's  semen  was  examined,  and  also  found 
to  be  quite  free  from  abnormality.  In  the  course  of  the  three  fol- 
lowing years  an  attempt  was  made  to  cure  the  sterility  by  dilatation 
of  the  cervical  canal,  suggestions  for  the  proper  regulation  of  sexual 
intercourse,  etc.,  but  all  without  effect.  Cohnstein  now  calculated 


THE  SEXUAL  EPOCH  OF  THE  MENACME.  549 

the  date  at  which  the  full  term  of  the  previous  pregnancy  would 
have  fallen,  and  found  that  this  was  the  middle  of  February;  he 
therefore  inferred  that  intercourse  effected  at  the  beginning  of 
May  would  result  in  impregnation.  As  a  fact,  the  woman  con- 
ceived at  this  time,  and  at  full  term  gave  birth  to  a  healthy  girl. 
The  assumption  that  such  a  time  of  predilection  for  the  occurrence 
of  conception  exists  is,  however,  contradicted  by  the  well  known  fact 
that  in  the  case  of  large  families  the  children's  birthdays  are  irreg- 
ularly distributed  throughout  the  year. 

Baker-Brown  describes  a  special  form  of  sterility  due  to  "  sym- 
pathetic or  reflex  action."  It  depends  upon  diseases  of  the  organs 
adjoining  the  uterus,  such  as  vascular  tumours  of  the  urethra,  bleed- 
ing piles,  fistula,  fissure,  and  prolapse  of  the  anus,  schirrus  of  the 
rectum,  ascarides.  "  These  diseases  produce  sterility  in  consequence 
of  the  loss  of  blood,  the  menstrual  disturbances,  the  morbid  con- 
gestion of  the  uterine  system,  and  the  reflex  neuroses,  to  which  they 
give  rise."  Courty  reports  a  case  belonging  to  this  category  in 
which  in  a  young  married  lady  sterility  was  due  to  fissure  of  the 
anus,  which  had  long  existed  without  recognition ;  after  the  fissure 
had  healed,  conception  occurred.  Palmay  recently  reported  a  case 
in  which  "  taenia  solium  was  the  cause  of  sterility.  In  a  woman 
20  years  of  age,  who  had  lived  in  sterile  wedlock  for  three  years, 
the  presence  in  the  intestine  of  a  tapeworm,  which  she  had  har- 
boured for  many  years,  gave  rise  to  dysmenorrhoeal  troubles.  The 
complete  expulsion  of  the  worm  relieved  the  dysmenorrhoea,  the 
woman  became  pregnant,  and  gave  birth  to  a  child  at  full  term; 
since  then  menstruation  has  been  painless."  The  presence  of  the 
tapeworm  may  have  had  an  unfavourable  influence  upon  the  blood- 
supply  and  the  innervation  of  the  uterus.  But  cases  of  this  nature 
do  not  constitute  a  special  form  of  sterility;  they  must  be  classed, 
either  with  cases  due  to  interference  with  ovulation,  or  with  those 
due  to  prevention  of  the  contact  of  ovum  and  spermatozoon. 

Incapacity  for  Incubation  of  the  Ovum. 

The  fertilization  of  the  ovum  is,  as  previously  described, 
probably  effected  in  man,  as  in  other  mammals,  in  the  upper 
third  of  the  Fallopian  tube.  The  fertilized  ovum  is  then  swept 
down  into  the  uterus  by  the  action  of  the  cilia  which  line 
the  tube,  assisted  by  the  peristaltic  movement  of  the  muscu- 
lar wall  of  the  canal.  The  uterine  mucous  membrane  at  this 
time  is  thickened  and  thrown  into  folds,  and  in  these  latter  the  fer- 
tilized ovum  is  entangled  ;  by  its  presence  the  ovum  now  exerts  a 
reflex  stimulus  leading  to  a  still  greater  proliferation  of  the  cells  of 
the  uterine  mucous  membrane,  which  grows  up  over  the  ovum  and 


550  THE  SEXUAL  LIFE  OF  WOMAN. 

soon  shuts  it  off  completely  from  the  uterine  cavity.  Thus  the 
ovum  comes  to  be  entirely  imbedded  in  the  substance  of  the  mucous 
membrane. 

Thus  for  the  implantation  of  the  ovum,  it  is  first  of  all  necessary 
that  the  uterine  mucous  membrane  should  be  in  a  normal  condition ; 
pathological  changes  in  this  membrane,  and  indeed  any  morbid 
structural  alteration  in  the  uterine  tissues,  may  prevent  the  implan- 
tation and  incubation  of  the  ovum,  and  may  thus  give  rise  to  sterility. 

The  uterine  cavity  is  normally  lined  with  ciliated  epithelium,  the 
cells  of  which  have  an  elongated  eliptical  form.  The  movement  of 
the  cilia  is  directed  downwards.  The  epithelium  is  perforated  by 
the  orifices  of  the  uterine  glands ;  these  glands  are  simple  tubular 
glands,  passing  through  the  mucous  membrane  with  an  S-shaped  or 
corkscrew  curve ;  between  the  glands  lies  a  rich  germinal  tissue, 
made  up  of  rounded  cells.  The  rounded  connective  tissue  cells  have 
processes  which  build  up  the  scaffolding  of  the  mucous  membrane. 
Among  the  connective  tissue  cells  of  the  uterine  mucous  membrane, 
wandering  leucocytes  are  almost  always  to  be  seen.  Menstruation 
is  characterized  by  a  swelling  of  the  mucous  membrane,  and  by  en- 
largement of  the  uterine  glands.  At  the  same  time,  blood  extrava- 
sations appear  between  the  more  superficial  layers  of  the  mem- 
brane, and  on  its  free  surface,  and  various  portions  of  the  surface 
of  the  membrane  are  cast  off. 

Very  numerous  are  the  morbid  states  of  the  uterus  and  its  annexa 
whereby  the  implantation  and  incubation  of  the  ovum  are  prevented  ; 
and  incapacity  of  the  uterus  for  the  fulfilment  of  these  functions  is 
therefore  a  common  cause  of  sterility  in  women. 

That  developmental  defects  of  the  uterus,  even  when  they  are  not 
such  as  render  conception  impossible,  may  yet  often  give  rise  to 
sterility,  has  been  already  explained  in  writing  of  the  conditions  of 
the  uterus  which  prevent  the  contact  of  ovum  and  spermatozoon; 
for  defects  of  development  which  are  not  sufficiently  severe  to  pre- 
vent this  contact,  may  yet  suffice  to  render  the  uterus  unfit  for  the 
implantation  and  incubation  of  the  fertilized  ovum.  Inflammatory 
disorders,  such  as  perimetritis  and  the  formation  of  exudations  in 
the  parametrium,  may  render  the  uterus  unable  to  undergo  the  en- 
largement necessary  to  pregnancy.  Tissue  changes  in  the  uterine 
musculature  may  likewise  prevent  the  implantation  of  the  ovum,  or 
the  proper  development  of  the  uterus  during  pregnancy.  New- 
growths  of  the  uterus  or  its  neighbourhood  may  bring  the  develop- 
ment of  the  fertilized  ovum  to  an  untimely  conclusion.  Above  all, 
however,  it  is  diseases  of  the  uterine  mucous  membrane  which  unfit 
the  organ  for  the  implantation  of  the  ovum,  and  thus  give  rise  to 
sterility.  All  those  inflammatory  states  which  lead  either  to  soften- 
ing or  to  induration  of  the  uterine  parenchyma,  or  to  swelling  and 


THE  SEXUAL  EPOCH  OF  THE  MENACME.  551 

thickening  of  the  endometrium  or  parametrium,  may  offer  a  hin- 
drance more  or  less  serious  to  the  normal  incubation  of  the  ovum. 

The  diagnosis  whether  in  an  individual  case  we  have  to  do  with 
sterility  dependent  upon  impotentia  gestandi,  is  often  difficult,  be- 
cause the  conditions  which  cause  it  are  frequently  associated  with 
those  which  cause  sterility  by  preventing  the  contact  of  ovum  and 
spermatozoon.  In  any  case,  a  careful  examination  of  the  pelvic 
organs  must  be  made,  not  only  to  determine  whether  there  is  any 
displacement  or  enlargement  of  the  uterus,  chronic  metritis  or  peri- 
metritis,  parametric  exudations,  or  new  growths  of  the  uterus  or  of 
neighbouring  organs,  but  also,  if  necessary  by  dilating  the  cervical 
canal,  to  ascertain  the  condition  of  the  uterine  mucous  membrane, 
and  whether  there  is  hyperplasia  or  atrophy  thereof.  In  this  con- 
nexion, examination  of  the  uterine  secretion  is  of  especial  impor- 
tance :  a  purely  mucous,  transparent,  vitreous,  tenacious  secretion  in 
the  os  and  in  the  cervical  canal,  indicates  the  existence  of  catarrhal 
endometritis ;  a  markedly  haemorrhagic  secretion  signifies  hyperplas- 
tic  endometritis ;  profuse  purulent  secretion  containing  gonococci, 
indicates  gonorrhoeal  endometritis ;  the  discharge  of  pieces  of  mem- 
brane shows  that  there  is  exfoliative  endometritis ;  the  discovery  of 
fragments  of  carcinomatous  tissue  indicates  the  breaking  down  of  a 
malignant  tumour  of  this  nature ;  etc. 

Finally,  it  is  necessary  to  obtain  a  careful  history  of  the  case,  ask- 
ing whether  there  have  been  menstrual  irregularities,  or  miscar- 
riages, and  the  characters  of  previous  labours  (in  cases  of  acquired 
sterility)  ;  any  pathological  conditions  in  other  organs  should  be  in- 
vestigated ;  and  the  condition  of  the  blood  and  the  state  of  general 
nutrition  should  receive  attention.  Chlorosis,  anaemia,  and  scrofula 
often  give  rise  to  catarrhal  endometritis ;  severe  disease  of  the  heart 
may  lead  to  congestive  troubles  of  the  genital  organs ;  after  abortion 
or  difficult  labour,  chronic  metritis  or  endometritis  are  common. 
Further,  the  differential  diagnosis  between  erosion  and  carcinoma  of 
the  portio  vaginalis,  must  often  depend  upon  consideration  of  the 
patient's  age  and  general  health,  and  upon  the  nature  and  duration 
of  the  haemorrhage.  Pain  on  micturition,  appearing  soon  after  mar- 
riage, and  lasting  often  a  few  days  only,  will  indicate  the  prob- 
ability of  gonorrhoeal  infection,  etc. 

Von  Grimewaldt  has  vigorously  insisted  upon  the  fact  that  the 
notion  of  sterility,  i.  e.,  impotentia  generandi  in  women,  is  not  co- 
incident with  the  notion  of  impotentia  concipicndi,  and  there  is  an 
important  distinction  between  cases  in  which  it  is  impossible  that 
fertilization  should  be  effected,  and  cases  in  which,  though  fertiliza- 
tion may  take  place,  the  implantation  and  incubation  of  the  ovum  fail 
to  ensue.  In  this  author's  opinion,  the  only  absolute  mechanical 
hindrance  to  the  entrance  of  the  semen  is  to  be  found  in  atresia  of 


COLLEGE  0! 
i- 1 '  \ 


552  THE  SEXUAL  LIFE  OF  WOMAN. 

the  genital  passage,  and  the  role  of  impotentia  concipiendi  is  of  quite 
minor  importance  as  compared  with  incapacity  on  the  part  of  the 
uterus  for  the  implantation  and  incubation  of  the  ovum,  an  opinion, 
which,  notwithstanding  the  record  of  exceptional  cases  in  which 
pregnancy  has  occurred  in  spite  of  the  existence  of  mechanical  ob- 
stacles to  conception,  I  must  regard  as  altogether  beyond  the  mark. 
On  the  other  hand,  it  is  indisputable  that  for  the  occurrence  of  preg- 
nancy it  ;s  necessary,  not  only  that  contact  of  ovum  and  spermato- 
zoon should  be  possible,  but  further,  that  the  uterus  should  be  in  a 
condition  favourable  for  the  implantation  and  further  development 
of  the  ovum  subsequent  to  fertilization.  For  this  reason,  diseases 
of  the  uterine  tissues  must  play  an  important  part  in  the  causation 
of  sterility,  though  we  cannot  go  so  far  as  to  admit  with  von  Grilnc- 
waldt  that  these  diseases  are  the  principal  cause  of  reproductive  in- 
capacity in  women. 

Various  metritic  processes,  and  also  venous  hyperaemia  conse- 
quent upon  heart  disease,  may  lead  to  atrophy  of  the  uterine  mucous 
membrane,  which  then  appears  thin  and  smooth,  whilst  the  uterine 
glands  are  destroyed,  or  transformed  into  small  cysts.  The  same 
condition  may  result  from  retention  of  secretions  in  the  uterine 
cavity  —  hydrometra  and  haematometra.  In  all  these  cases,  the  epi- 
thelium probably  loses  its  cilia.  The  process  has  a  serious  influence 
antagonistic  to  the  reproductive  capacity  inasmuch  as  the  implanta- 
tion of  the  chorionic  villi  is  rendered  difficult  (Klebs}. 

Hyperplasia  of  the  uterine  parenchyma,  affecting  either  the  whole 
organ  or  a  large  part,  and  characterized  either  by  enlargement  of 
the  entire  organ,  or  only  by  thickening  and  elongation  of  the  cervix, 
may  hinder  the  incubation  of  the  ovum.  It  may  be  due  to  endomet- 
ritic  catarrhal  processes ;  to  venous  hyperaemia,  especially  in  cases 
of  valvular  heart  disease ;  to  subinvolution ;  and  sometimes  to  ex- 
cessive sexual  stimulation,  as  in  prostitutes.  Both  the  change  in 
the  shape  of  the  cervix,  and  the  changes  undergone  by  the  uterine 
mucous  membrane  in  cases  of  extensive  uterine  hyperplasia  (it  com- 
monly becomes  atrophic  and  discharges  a  watery  secretion),  inter- 
fere with  the  reproductive  capacity. 

In  all  cases  of  chronic  metritis,  the  hyperaemia  and  hyperplasia  of 
the  uterus  may  give  rise  to  haemorrhages ;  these  sweep  away  the 
ovum,  and  thus  lead  to  impotentia  gcstandi.  And  the  nutritive 
changes  in  the  mucous  membrane  that  occur  in  chronic  metritis  also 
interfere  with  the  implantation  and  incubation  of  the  ovum.  More- 
over, it  is  well  known  that  in  these  cases,  even  if  conception  is 
effected,  abortion  is  extremely  apt  to  occur,  owing  to  the  pathologi- 
cal state  of  the  endometrium,  which  interferes  with  the  normal  de- 
velopment of  the  decidua.  Haemorrhages  occur  in  the  decidua,  and 
are  followed  by  abortion.  And  further,  the  replacement  of  portions 


T  f\  T    f     r  r    f 

d  rf  3  J  J  u  .j 

t/  /    (  ^    r  /".  •/•  i  r  rr 


THE  SEXUAL  EPOCH  OF  THE  MENACME.  553 

of  the  muscular  tissue  of  the  uterine  wall  by  fibrous  tissue,  a  change 
which  is  apt  to  occur  in  long  continued  metritis,  interferes  with  the 
proper  expansion  of  the  uterus  during  pregnancy,  and  thus  leads  to 
abortion. 

On  the  other  hand,  it  cannot  be  denied  that  frequently  enough 
patients  with  well  marked  chronic  metritis  nevertheless  conceive  in 
a  normal  manner,  and  give  birth  to  a  healthy  child;  and  this  not 
once  only,  but  again  and  again. 

As  sterility  due  to  mesometritis,  von  Gruncwaldt  classes  the 
numerous  cases  in  which  sterility  ensues  upon  a  confinement  in 
which  the  patient  reports  that  inflammation  followed  delivery  —  or 
sometimes  in  which  nothing  abnormal  was  noticed.  The  results  of 
local  examination  are  negative :  there  is  no  displacement,  no  exuda- 
tion or  swelling,  and  no  relevant  affection  of  the  endometrium.  But 
the  characteristic  feature  of  these  cases  is,  according  to  von  Griine- 
waldt,  that  after  her  last  full-time  delivery,  a  woman  has  had  a  mis- 
carriage or  a  premature  delivery,  and  subsequently  has  been  com- 
pletely sterile.  The  degenerative  process  is  at  first  partial,  so  that 
it  does  not  prevent  conception,  but  renders  it  impossible  for  the 
pregnancy  to  go  on  to  full  term ;  subsequently  it  extends  throughout 
the  mesometrium,  and -conception  is  no  longer  possible. 

Cole  of  San  Francisco  regards  as  the  most  frequent  cause  of 
sterility  ensuing  upon  a  single  delivery,  subinvolution  of  the  uterus, 
most  commonly  due  to  rising  too  early  after  delivery.  He  therefore 
considers  it  of  especial  importance  after  a  first  delivery  that  the  phy- 
sician should  satisfy  himself  that  no  serious  injury  has  been  effected 
by  the  process. 

Chronic  endometritis  is  a  very  frequent  cause  of  sterility:  in  the 
first  place,  the  catarrhal  swelling  of  the  mucous  membrane,  which 
often  extends  from  the  os  uteri  externum  to  the  ostium  abdominale 
of  the  Fallopian  tubes,  offers  an  obstacle  alike  to  the  downward 
passage  of  the  ovum  and  the  upward  passage  of  the  spermatozoa ; 
and  secondly,  in  long  standing  cases,  the  large  size  of  the  uterine 
cavity  and  the  smoothness  of  the  surface  of  the  atrophied  mucous 
membrane,  render  the. lodgment  of  the  ovum  in  the  uterus  very  un- 
likely. A  further  powerful  obstacle  to  impregnation  in  cases  of  en- 
dometritis is  offered  by  the  profuse  muco-purulent  secretion,  which 
usually,  though  not  invariably,  accompanies  that  disease.  This 
secretion,  in  some  cases  flowing  freely  over  the  surface  of  the  mem- 
brane, but  in  others  adhering  to  it  with  tenacity,  whitish-yellow  in 
colour,  rendered  cloudy  by  admixture  of  pus,  or  tinted  red  by  ad- 
mixture of  blood,  sometimes  of  a  gelatinous  consistency  with  a 
strongly  alkaline  reaction,  contains  globules  of  mucus,  ciliated  and 
cylindrical  epithelial  cells,  pus  corpuscles,  bacteria  and  cocci, —  and, 
if  the  endometritis  is  of  gonorrhoeal  origin,  the  gonococcus  of 


554 


THE  SEXUAL  LIFE  OF  WOMAN. 


Ncisscr.  This  secretion,  when  profuse  and  thinly  fluid,  pours  out 
through  the  os,  and  sweeps  away  the  semen ;  when  tenacious  and 
gelatinous,  it  fills  up  the  dilated  cervical  canal  above  the  constricted 
os  uteri  externum,  and  constitutes  a  powerful  barrier  to  the  upward 
passage  of  the  spermatozoa;  when  purulent,  it  is  destructive  to  the 
vital  activity  of  the  spermatozoa.  The  changes  in  the  mucous  mem- 
brane in  cases .of  long  standing  endometritis  whereby  the  uterus  is 
rendered  unfit  for  the  implantation  and  incubation  of  the  ovum,  are 
the  following.  The  epithelial  cells,  as  usual  in  cases  of  continued 
catarrh,  change  in  form,  the  ciliated  cells  disappear,  and  are  re- 
placed, first  by  cylindrical  cells,  later  by  polymorphic  cells,  approach- 
ing in  type  those  of  pavement  epithelium.  The  mucous  membrane 
is  swelled,  the  vessels  are  dilated,  there  is  hyperplasia  of  the  glands, 
with  a  moderate  amount  of  small-celled  infiltration  of  the  interglan- 


FIG.  83.  —  Uterine  Mucous  Membrane  in  Endometritis.     (After  A.  Martin.) 


dular  tissue  (Fig.  83).  Ultimately  the  mucous  membrane  under- 
goes atrophy,  its  glands  disappear,  it  comes  to  resemble  a  thin 
stratum  of  connective  tissue. 

Thus,  in  severe  and  long-continued  endometritis,  the  changes  that 
occur  in  the  uterine  mucous  membrane  render  the  implantation  of 


THE  SEXUAL  EPOCH  OF  THE  MENACME.  555 

the  ovum  and  the  formation  of  normal  decidua  impossible;  even  if 
conception  does  occur,  the  fertilized  ovum  is  speedily  discharged. 
Frequently,  in  cases  of  endometritis,  there  is  consecutive  displace- 
ment of  the  uterus  which  acts  as  a  contributory  cause  of  sterility. 
When  endometritis  lasts  a  long  time,  proliferation  of  connective 
tissue  in  the  uterine  parenchyma  also  occurs,  leading  often  to  hyper- 
trophy of  the  cervix,  and  to  stenosis  of  the  cervical  canal.  Since  in 
so  many  different  ways  endometritis  may  give  rise  to  sterility,  the 
importance  that  must  be  attached  to  this  condition  is  evident. 

The  great  significance  of  gonorrhoeal  infection  in  relation  to  steril- 
ity in  women  depends,  not  only  on  the  changes  this  disease  causes 
in  the  Fallopian  tubes,  leading  to  interference  with  the  necessary  con- 
tact of  ovum  and  spermatozoon,  but  further,  upon  the  occurrence  of 
gonorrhoeal  cervical  and  corporal  endometritis,  of  perimetritis,  and 
secondary  parenchymatous  metritis.  Still,  under  appropriate  treat- 
ment, the  inflammatory  changes  consequent  on  gonorrhoeal  infection 
are  in  many  cases,  curable,  and,  after  absorption  of  the  exudations 
and  restoration  of  the  normal  nutritive  conditions  of  the  tissues,  con- 
ception may  take  place.  Fritsch,  who  points  out  that  in  the  woman 
infected  with  gonorrhoea,  sterility  ensues  in  a  manner  analogous  to 
that  in  which  it  occurs  in  the  male  (for  in  the  latter  it  is  not  the 
primary  urethritis,  the  disease  of  the  passage,  but  the  secondary  in- 
flammation of  the  testicle  that  leads  to  sterility),  states  that  he  has 
observed  cases  in  which  beyond  question  conception  has  occurred, 
notwithstanding  the  existence  of  gonorrhoeal  endometritis. 

In  my  own  experience,  whilst  gonorrhoeal  endometritis  is,  among 
inflammations  of  the  endometrium,  the  most  frequent  cause  of  steril- 
ity, the  place  of  next  importance  in  this  connexion  is  occupied  by 
exfoliative  endometritis,  or  membranous  dysmenorrlloea.  This  name 
is  given  to  a  pathological  condition  in  which  from  time  to  time, 
usually  during  menstruation,  fragments  of  membrane,  or  even  an 
entire  sac-like  cast  of  the  uterine  cavity,  are  expelled  from  the 
uterus;  since  this  condition  is  apt  to  hinder  the  incubation  of  the 
ovum,  it  is  commonly  associated  with  sterility  —  a  fact  mentioned 
already  by  Denman  in  1790,  and  since  then  confirmed  by  numerous 
observers.  1  have  had  under  observation  several  cases  of  dysmenor- 
rhoea  membranacea;  in  two  cases  it  existed  from  the  time  of  mar- 
riage—  in  one  case  14  years,  in  the  other  8  years  —  and  in  both 
sterility  was  absolute.  In  the  latter  of  the  two  cases,  vigorous  treat- 
ment was  undertaken,  even  curettage  of  the  uterus,  but  quite  without 
avail.  In  other  cases,  the  sterility  was  acquired,  the  membranous 
dysmenorrhoea  having  b3gun  after  the  woman  had  already  had  one 
or  more  children ;  but  as  I  have  never  seen  a  case  in  which  a  woman 
became  pregnant  after  the  development  of  this  affection,  I  am  com- 
pelled to  regard  it  as  one  of  the  most  severe  hindrances  to  concep- 
tion. 


556  THE  SEXUAL  LIFE  OF  WOMAN. 

As  a  general  rule,  exfoliative  endometritis  terminates  only  with 
the  onset  of  the  climacteric  age ;  in  very  exceptional  cases,  however, 
a  cure  may  take  place  earlier.  In  cases  in  which  this  premature  ter- 
mination has  been  observed,  pregnancy  has  been  known  to  ensue, 
cases  of  this  nature  having  been  observed  by  Solowieff,  Fordyce 
Barker,  and  Thomas.  And  recently,  cases  have  been  reported,  in 
which  the  disease  has  returned  after  such  a  pregnancy.  Fritsch,  in- 
deed, is  of  opinion  that  exfoliative  endometritis  does  not  cause 
sterility,  and  that  in  this  disease  abortion  is  no  commoner  than  in 
other  diseases  of  the  uterus.  Charpignon,  Hennig,  and  Bordicr  have 
also  observed  conception  occur  in  the  course  of  this  disease.  In  42 
cases  of  membranous  dysmenorrhoea  collected  by  Kleinwdchter^ 
pregnancy  occurred  in  four  during  the  existence  of  the  disease. 
Lohlcin  also  reports  that,  among  27  patients  affected  with  membran- 
ous dysmenorrhoea,  six  became  pregnant,  after  the  symptoms  had 
been  clear  and  unmistakable  for  a  shorter  or  longer  period.  Two  of 
these  patients  had  been  already  pregnant  before  the  first  appearance 
of  the  exfoliative  endometritis;  subsequently  they  became  pregnant 
and  were  delivered  at  full  term.  The  other  four  had  suffered  for 
varying  periods  and  with  varying  severity  from  the  affection,  before 
they  first  became  pregnant.  In  three  of  these  cases  curettage  of  the 
uterus  was  performed ;  but  in  one  only,  in  which  pregnancy  ensued 
very  speedily  on  the  operation,  could  a  causal  connexion  be  inferred. 
In  two  of  the  cases  the  mothers  of  the  patient  had  also  suffered 
from  the  affection. 

It  has  been  asserted  by  B.  Schultse  and  others  that  curettage  of 
the  uterus  renders  it  difficult  or  impossible  for  pregnancy  subse- 
quently to  occur.  There  is,  however,  no  evidence  to  justify  such  an 
opinion. 

Especial  attention  should  be  given  to  inflammatory  processes  in 
the  perimetrium  and  the  parametrium  as  diseases  giving  rise  to  steril- 
ity in  women.  They  are  extremely  common,  and  at  times  are 
so  insidious,  running  their  course  without  giving  rise  either  to  pain 
or  to  fever,  that  even  when  very  extensive,  and  even  when  they  have, 
led  to  the  formation  of  secondary  tumour-growths,  they  may  yet  be 
overlooked.  Hence  their  pathological  significance  in  the  causation 
of  sterility  in  women  is  still  underestimated.  Chronic  pelvic  peri- 
tonitis and  parametritis  may  lead  to  the  onset  of  sterility  in  various 
ways:  changes  may  occur  in  the  cervix,  this  organ  becoming  indu- 
rated, fixed,  and  retroposed,  and  painful  when  the  uterus  is  moved ; 
inflammatory  changes  may  affect  the  body  of  the  uterus,  the  liga- 
ments of  the  ovary,  and  various  portions  of  the  pelvic  peritoneum ; 
displacement  of  the  uterus  may  occur ;  one  or  both  ovaries  or  tubes 
may  be  dislocated  and  fixed,  either  to  the  side  of  the  uterus,  or 
behind  it,  in  the  pouch  of  Douglas;  all  kinds  of  adhesions  or  in- 


THE  SEXUAL  EPOCH  OF  THE  MENACME.  557 

fiammatory  nodules  may  result  from  these  processes.  Further,  in 
the  scarred,  contracted,  sclerosed  parametric  tissue,  the  blood  and 
lymphatic  vessels  of  the  parametrium  are  compressed,  and  in  part 
obliterated,  and  the  intimate  connexion  between  the  pelvic  cellular 
tissue  and  the  uterus  readily  leads  to  the  onset  of  endometritis, 
whereby  the  implantation  of  the  ovum  is  interfered  with.  The  oc- 
currence of  sterility  in  cases  of  pelvic  peritonitis  and  parametritis, 
depends  in  part  on  the  indirect  effects  of  the  inflammatory  exuda- 
tions, and  in  part  on  the  direct  result  of  the  extension  of  the  inflam- 
mation to  other  regions.  The  perimetritis,  parametritis,  and  pelvic 
peritonitis  that  result  from  gonorrhoeal  infection  have  thus  an 
especially  disastrous  influence,  for  the  reason  that  in  these  cases 
cervical  metritis  and  endometritis  with  blenorrhoea  are  commonly 
superadded.  This  is  the  principal  cause  of  the  almost  invariable 
sterility  of  prostitutes,  in  whom,  however,  we  must  also  take  into 
consideration  the  influence  of  the  absence  of  voluptuous  sensation 
in  an  act  which  to  them  has  become  a  mere  matter  of  business. 
The  investigations  of  Bandl  in  the  post  mortem  room  show  that 
residues  of  perimetritic  and  parametritic  inflammation  are  to  be 
found  in  the  bodies  of  58.4^  of  parous  women,  and  33.3^  of  the 
bodies  of  women  (married  or  unmarried)  who  have  had  experience 
of  sexual  intercourse  but  have  never  had  a  child.  This,  he  thinks, 
is  the  explanation  of  the  great  frequency  of  childless  marriages  and 
of  relative  sterility  in  women.  In  the  nulliparae  mentioned  above, 
Bandl  commonly  found  an  indurated,  functionless,  in  places  cica- 
trized, narrowed  cervix,  paraoophoritic  and  perisalpingitic  residues, 
and  morbid  changes  in  the  tubes  and  the  ovaries.  In  some  cases  also 
the  husbands  of  such  sterile  women  were  found  to  be  affected  with 
azoospermia.  The  connexion  between  azoospermia  in  men  and  the 
discovery  of  inflammatory  residues  in  their  childless  wives,  is  a  very 
intimate  one.  The  husband  at  the  time  of  marriage  was  suffering 
from  an  imperfectly  cured  gonorrhoea,  and  infected  his  wife.  In 
the  other  class  of  cases,  in  which  the  women  had  had  children,  and 
subsequently  become  sterile,  the  limitation  of  fertility  depended 
chiefly  upon  inflammatory  residues  in  and  around  the  ovaries  and 
the  tubes.  In  the  majority  of  such  cases,  pregnancy  is  not  rendered 
impossible,  but  merely  difficult,  for,  notwithstanding  the  presence 
of  very  extensive  inflammatory  residues,  the  tubes  are  often  per- 
vious, and  the  ovaries  fully  or  partially  functional.  Therefore,  even 
in  cases  in  which  intra-pelvic  inflammation  has  been  very  severe, 
\ve  must  be  cautious  in  giving  a  prognosis  that  pregnancy  has  been 
rendered  impossible,  for  the  cases  in  which  both  ovaries  are  im- 
bedded completely  in  pseudo-membranes,  or  in  which  both  tubes 
have  been  rendered  impervious,  are  unquestionably  rare. 


558  THE  SEXUAL  LIFE  OF  WOMAN. 

Carcinoma  of  the  uterus  rarely  causes  sterility.  In  its  initial 
stages,  in  which  there  is  merely  papillary  proliferation  of  the  portio 
vaginalis,  or  carcinomatous  infiltration  of  the  deeper  layers  of  the 
mucous  membrane,  no  hindrance  is  offered  to  conception ;  but  even 
in  the  later  stages  of  the  disease,  when  ulceration  has  occurred, 
and  when  there  is  extensive  necrosis  of  the  cancerous  masses,  there 
is  not  necessarily  any  absolute  impossibility  of  the  occurrence  of 
conception,  so  long  as  cohabitation  remains  possible,  and  no  in- 
superable hindrance  has  risen  to  the  contact  of  ovum  and  sperma- 
tozoon. The  cases  are  numerous  in  which  pregnancy  has  been 
observed,  notwithstanding  extensive  carcinomatous  disease  of  the 
cervix,  with  necrosis  of  the  tumour  tissue;  and  Cohnstcin  even  as- 
serts, though  in  this  he  goes  too  far,  that  cancer  of  the  cervix 
actually  favours  impregnation.  Among  127  cases  of  this  kind, 
there  were  21  in  which  the  disease  had  existed  for  a  year  or  more 
before  the  occurrence  of  conception. 

Winckel  summarizes  in  the  three  following  propositions  his  ex- 
perience regarding  the  relation  between  uterine  carcinoma  and 
sterility:  I.  Married  women  form  the  very  large  majority  of  those 
affected  with  carcinoma  of  the  uterus;  2.  The  marriage  of  such 
women  has  very  rarely  proved  sterile ;  3.  On  the  contrary,  the 
women  affected  with  this  disease  have  generally  been  exceptionally 
fertile. 

Other  tumours  of  the  uterus  cause  sterility,  not  merely  by  giving 
rise  to  mechanical  interference  with  the  necessary  contact  of  ovum 
and  spermatozoon,  but  also  by  leading  to  catarrhal  states  and  hyper- 
plasia  of  the  mucous  membrane,  which  interfere  with  the  implan- 
tation of  the  ovum,  even  when  fertilization  has  been  effected. 
Uterine  polypi  give  rise  to  mechanical  obstruction  of  the  os  uteri 
externum  or  of  the  cervical  canal ;  but  they  predispose  to  sterility 
in  an  additional  way,  inasmuch  as  in  a  woman  affected  with  such  a 
new  growth  any  vigorous  bodily  movement  is  apt  to  cause  profuse 
uterine  haemorrhage. 

In  cases  of  myoma  of  the  uterus,  apart  from  the  mechanical 
hindrances  to  conception  imposed  by  these  tumours,  there  is  also 
interference  with  the  implantation  of  the  ovum.  When  numerous 
myomata  have  formed  in  the  uterine  wall,  the  mucous  membrane 
is  usually  smooth  and  atrophied,  and  discharges  a  watery  secretion, 
and  for  these  reasons  the  imbedding  of  the  ovum  in  the  uterine 
cavity  is  rendered  extremely  difficult.  But  that  there  is  often  an 
additional  cause  of  sterility  in  cases  of  myomata  uteri,  has  been 
shown  by  the  researches  of  Schorlcr,  who  examined  822  patients 
affected  with  fibromyoma  of  the  uterus.  He  found  that  in  most 
of  those  in  whom  sterility  was  observed,  the  tumours  were  not 
submucous  but  subserous,  and  that  the  sterility  was  to  be  explained 


THE  SEXUAL  EPOCH  OF  THE  MENACME.  559 

in  these  cases  by  the  frequent  occurrence  of  partial  peritonitis,  with 
its  evil  results  to  the  uterine  annexa. 
Schorler  appends  the  following  table : 

Per- 
Steriie.      centage. 

Of  85  women  with  interstitial  myoma  21  24.7 

Of  92  women  with  subserous  myoma 44  47.8 

Of  18  women  with  submucous  myoma 7  38.8 

Of  44  women  with  polypous  myoma    4  9.0 

Of  14  women  with  cervical  myoma 3  18.7 


253  79  31-2 

When  there  are  polypous  new  formations  in  the  uterine  cavity, 
even  if  conception  occurs,  abortion  follows,  for  the  reason  that  the 
rupture  of  the  hypertrophied  capillaries  in  the  growths  themselves 
and  in  the  neighbouring  tissues,  prevents  the  normal  development  of 
the  embryo.  Horivitz  has,  however,  described  a  case  in  which 
pregnancy  went  on  to  full  term,  notwithstanding  the  existence  of 
growths  of  this  nature. 

Owing  to  the  frequency  with  which  chronic  metritis  and  endome- 
tritis  ensue  upon  parturition,  it  can  readily  be  understood  that  de- 
livery itself  is  often  the  primary  cause  of  subsequent  sterility.  A 
temporary  sterility  often  follows  the  first  delivery.  It  is  well  known 
that  the  birth  of  boys  is  in  general  more  difficult  than  the  birth 
of  girls;  Pfankuch  collecting  information  regarding  the  first  and 
second  deliveries  of  300  married  women,  ascertained  that  after  166 
of  the  first  deliveries,  in  which  boys  were  born,  the  average  lapse  of 
time  to  the  second  delivery  was  30.2  months,  whereas  after  134  of 
the  first  deliveries  in  which  girls  were  born,  the  average  lapse  of 
time  to  the  second  delivery  was  only  27.4  months. 

The  importance  of  previous  delivery  in  leading  to.  sterility,  in 
consequence  of  mesometritis  and  diffuse  connective  tissue  hyper- 
plasia  of  the  uterus,  is  shown  by  von  Gri'mewaldt,  who  published 
the  following  figures  as  a  result  of  his  investigations.  Of  56 
women  affected  with  chronic  metritis,  46.4$  were  sterile;  in  19.2$ 
of  these  the  sterility  was  congenital,  in  80.7$  it  was  acquired.  Of 
134  women  suffering  from  myometritis  and  its  consequences,  71.6^ 
•were  sterile;  in  17.7  of  these  the  sterility  was  congenital,  and  in 
82.2$  it  was  acquired.  On  the  other  hand,  of  321  women  suffer- 
ing from  endometritis,  29.5^  were  sterile;  in  28.4$  of  these  the 
sterility  was  congenital,  and  in  71.5^  it  was  acquired. 

Licr  and  Aschcr  also  insist  upon  the  importance  of  puerperal 
diseases  in  the  causation  of  acquired  sterility,  basing  their  opinion 
upon  Prochownick's  clinical  material.  They  draw,  however,  the 
following  distinction.  If  the  puerperal  infection  takes  place  by  way 
of  the  external  organs  of  reproduction,  through  the  vagina  to  the 


560  THE  SEXUAL  LIFE  OF  WOMAN. 

cervix  and  thence  to  the  connective  tissue  of  the  pelvis  —  the  most 
common  form,  that  which  occurs  soonest  after  delivery,  and  the 
most  severe  in  its  course  —  the  women  thus  affected  are  likely  soon 
to  become  pregnant  again ;  if,  on  the  other  hand,  the  disease  is  pel- 
vic peritonitis,  the  exciting  cause  of  the  inflammation  proceeding 
from  the  interior  of  the  uterus  through  the  Fallopian  tubes  to  reach 
the  peritoneum,  in  the  majority  of  cases  the  women  thus  affected 
will  proye  sterile  for  a  long  time  or  in  perpetuity.  In  almost  all  the 
cases  in  which  sterility  resulted,  the  pelvic  peritoneum  had  been 
severely  affected  by  the  puerperal  inflammation.  Regarding  steril- 
ity in  women,  the  two  following  general  propositions  are  laid  down 
by  Licr  and  Aschcr:  i.  Hardly  any  single  cause  of  sterility  in 
women  is  so  severe  as  to  be  competent  by  itself  to  render  sterility 
inevitable  throughout  the  period  of  sexual  maturity,  with  the  excep- 
tion of  defects  of  development  and  premature  cessation  of  sexual 
activity.  2.  Most  of  the  hindrances  to  conception  in  women  de- 
pend upon  affections  of  the  internal  superficies  of  the  reproductive 
organs,  from  the  vulval  mucous  membrane  upwards  to  the  pelvic 
peritoneum;  of  these,  the  most  important  are  affections  of  the  en- 
dometrium. 

On  the  other  hand,  it  must  not  be  forgotten,  that  the  general 
tendency  of  a  previous  delivery  is  to  increase  the  capacity  for  im- 
pregnation. Olshausen  especially  insists  upon  the  well-known 
gynecological  fact,  that  as  a  result  of  the  first  delivery,  there  occurs 
an  enlargement  of  the  os  uteri,  which  facilitates  conception  through- 
out the  remainder  of  the  period  of  sexual  maturity.  This  is  well 
shown  by  the  not  infrequent  cases  in  which  sterility  persists  for 
several  years  after  marriage,  and  then,  with  or  without  artificial  aid, 
the  first  pregnancy  occurs;  thereafter  one  child  after  another  ap- 
pears in  rapid  succession. 

Spicgelbcrg  has  pointed  out  that  cervical  lacerations  may  give 
rise  to  sterility  by  interference  with  the  incubation  of  the  ovum. 
Olshausen  maintains  that  this  affection  is  liable  to  cause  abortion, 
for  the  reason  that  by  the  gaping  of  the  cervical  canal  the  inferior 
pole  of  the  ovum  is  from  time  to  time  exposed,  and  this  gives  rise 
to  reflex  contractions  of  the  uterus. 

Von  Grunewaldt  publishes  figures  in  support  of  his  opinion  that 
disturbances  of  the  integrity  of  the  uterus,  whereby  the  implanta- 
tion and  further  development  of  the  ovum  are  interfered  with,  play 
on  a  whole  a  greater  part  in  the  causation  of  sterility  than  the 
various  conditions  previously  described  which  interfere  with  contact 
of  ovum  and  spermatozoon.  But  in  this,  we  think,  he  goes  too  far. 

Finally,  in  this  connexion,  must  be  mentioned  among  the  hin- 
drances to  fertilization,  sexual  excesses,  such  as  are  so  common  dur- 
ing the  first  weeks  of  married  life.  Too  frequent  coitus  gives  rise  to 


THE  SEXUAL  EPOCH  OF  THE  MENACME.  561 

enduring  congestion  of  the  uterus,  and  hence  to  an  irritable  state  of 
the  uterine  mucous  membrane,  whereby  the  implantation  of  the 
ovum  is  rendered  difficult.  In  prostitutes  chronic  metritis,  due  to 
the  excessive  frequency  of  intercourse,  may  be  a  contribute^  cause 
of  the  sterility  which  is  almost  invariable  in  these  women ;  doubt- 
less, however,  the  principal  cause  of  their  sterility  is  gonorrhoeal 
perimetritis. 

As  a  variety  of  the  third  kind  of  sterility,  sterility  due  to  inca- 
pacity for  implantation  or  further  development  of  the  ovum,  must 
be  classed  the  cases  in  which,  though  conception  and  implantation 
of  the  ovum  are  known  to  occur,  and  the  first  stages  of  develop- 
ment of  the  embryo  certainly  take  place,  the  woman  proves  inca- 
pable of  giving  birth  to  a  viable  infant.  Some  of  these  cases  depend 
upon  abnormal  modes  of  development,  myxoma  of  the  chorion  and 
the  like.  In  rare  cases,  women  abort  every  month,  discharging 
every  four  weeks  a  fully  developed  decidua  vera,  in  which  some- 
times no  trace  of  ovum  can  be  detected.  But  this  monthly  abortion 
ceases  as  soon  as  marital  relations  are  interrupted. 

It  would  be  passing  beyond  the  scope  of  this  work  to  discuss  the 
pathological  processes  which  lead  to  premature  interruption  of  the 
pregnancy,  after  conception,  implantation  of  the  ovum,  and  the  first 
stages  of  development,  have  occurred  in  a  normal  manner;  to  dis- 
cuss, in  short,  the  causes  of  abortion.  Moreover,  these  pathological 
processes  are  outside  the  concept  of  sterility.  It  is  sufficient  here 
to  enumerate  the  principal  conditions  in  which  abortion  occurs. 
They  are :  various  tissue  disorders  of  the  uterus,  chronic  hyper- 
aemia  of  the  mucosa,  displacement  of  the  uterus  with  fixation,  para- 
metric and  perimetric  exudations,  laceration  of  the  cervix  with 
ectropium;  further,  various  constitutional  disorders,  such  as  the 
specific  fevers,  acute  infective  processes,  chronic  circulatory  dis- 
turbances consequent  upon  cardiac,  pulmonary,  renal  and  hepatic 
disease,  syphilis,  anaemia,  chlorosis,  diabetes,  etc. 

Only-Child-StcrUity. 

Until  recently,  only-child-sterility  had  received  attention  in  Eng- 
land only,  for  the  reason  that  it  is  comparatively  common  in  that 
country ;  but  this  form  of  relative  sterility  is  by  no  means  rare  with 
us  (in  Germany  and  Austria)  also.  I  had  a  collection  made  in 
Austria  of  the  number  of  children  resulting  from  2000  fruitful 
unions,  and  found  that  among  these  there  were  105  marriages  in 
which  one  child  only  had  been  born ;  thus  the  ratio  of  these  mar- 
riages to  those  which  proved  fully  fruitful  was  about  1:19.  But 
the  figures  are  untrustworthy,  since  abortions  and  deaths  in  infancy 
were  not  taken  into  account.  Ansell  found  that  in  England,  among 

36 


562  THE  SEXUAL  LIFE  OF  WOMAN. 

1767  fruitful  marriages  in  which  the  mean  age  of  the  wives  at  mar- 
riage had  been  25,  there  were  131  cases  of  only-child-sterility,  giv- 
ing a  ratio  of  the  latter  to  the  fully  fruitful  unions  of  1:13. 

This  form  of  relative  sterility,  in  which  the  wife  gives  birth  to 
one  child,  and  thereafter  remains  barren,  was  referred  by  Matthews 
Duncan,  either  to  a  premature  exhaustion  of  the  reproductive  ca- 
pacity, the  generally  bodily  powers  remaining  unaffected,  or  else  to 
a  simultaneous  weakening  of  the  sexual  powers  and  of  the  consti- 
tutional force  in  general.  This  explanation  is  a  very  inadequate  one. 
The  significant  fact  upon  which  an  understanding  of  the  nature  of 
only-child-sterility  must  be  based,  is  that  the  first  delivery  is  the 
one  which  entails  the  greatest  dangers  to  the  mother,  and  that  the 
subsequent  sterility  is  attributable  to  the  difficult  delivery,  and  to 
the  illnesses  that  follow  in  its  train.  In  fact,  only-child-sterility  is 
observed  chiefly  after  difficult  deliveries,  followed  by  long  enduring 
inflammatory  processes  of  the  uterus  and  the  uterine  annexa,  which 
seriously  affect  the  woman's  reproductive  capacity.  It  occurs  espe- 
cially in  delicately  organized,  anaemic,  scrofulous  women,  whose 
powers  of  resistance  have  been  undermined  by  a  single  pregnancy 
and  parturition.  Finally,  it  is  met  with  in  women  suffering  from 
myoma  uteri,  a  form  of  tumour  which  beyond  others  renders  the 
recurrence  of  pregnancy  difficult  and  unlikely.  This  form  of  steril- 
ity has  been  seen  also  in  cases  in  which  comparatively  soon  after  the 
birth  of  her  first  child,  the  mother  has  suffered  from  typhoid,  scar- 
latina, or  some  other  severe  infective  fever,  which  appears  in  some 
way  to  interfere  for  the  future  with  the  development  of  normal  ova. 
We  must  also  take  into  consideration  the  fact  that  at  the  time  of 
the  wife's  first  confinement,  when  the  love  which  brought  about  the 
union  has  often  already  begun  to  diminish  in  intensity,  the  husband, 
finding  too  irksome  the  continence  enforced  upon  him  by  his  wife's 
condition,  is  not  unlikely  to  go  elsewhere  for  temporary  sexual 
gratification,  and  to  acquire  a  venereal  disease,  which  he  subse- 
quently transmits  to  his  wife,  and  which  is  responsible  for  the  lat- 
ter's  future  sterility.  And  we  must  not  forget  to  take  into  account 
the  adoption  of  means  for  the  prevention  of  pregnancy  after  the 
first  child  has  been  born.  Again,  I  saw  three  cases  of  only-child- 
sterility  in  which  the  husbands  were  respectively  24,  26,  and  29 
years  older  than  their  wives,  and  in  these  instances  no  profound 
search  was  needful  for  the  discovery  of  the  cause  of  the  wife's  un- 
fruitfulness ;  it  was  obvious  that  in  each  case  the  elderly  husband's 
reproductive  powers  had  sufficed  for  the  procreation  of  a  single 
child,  but  had  then  been  completely  exhausted.  My  experience  in 
the  mysteries  of  sterility  in  women  has  informed  me  of  yet  another 
cause  of  only-child-sterility,  met  with  in  cases  in  which  the  only 
child  was  born  after  several  years  of  unsuccessful  marital  inter- 


THE  SEXUAL  EPOCH  OF  THE  MENACME.  563 

course.  In  most  of  these  cases,  the  wife  has  finally  been  impelled 
to  seek  a  substitute  for  her  husband,  whose  reproductive  powers 
have  proved  insufficient;  having  succeeded  in  obtaining  the  child 
she  desires,  the  wife  does  not  again  wander  in  strange  pastures,  and 
consequently  remains  sterile. 

According  to  Kleinwdchter  —  who  gives  a  somewhat  wider  sig- 
nificance to  the  term  "  only-child-sterility,"  including  as  he  does 
cases  of  premature  interruption  of  the  first  and  only  pregnancy, 
since  these  even  more  frequently  entail  permanent  sterilization  — 
only-child-sterility  is  by  no  means  rare.  Among  1081  gynecological 
cases,  he  observed  it  in  90,  that  is,  in  8.32$  of  the  cases.  In  these 
90  cases,  there  were  69  instances  in  which  the  sterility  ensued  upon 
full  term  delivery,  and  21  instances  in  which  it  followed  abortion 
or  premature  delivery.  Kleinwdchter,  moreover,  on  the  basis  of  his 
personal  experience,  supports  my  view  of  the  importance  of  the 
sterilizing  influence  of  the  first  delivery ;  but  he  has  been  unable  to 
determine  whether  early  marriage  has  any  influence  in  the  produc- 
tion of  only-child-sterility. 

Licr  and  Ascher  also  class  as  instances  of  only-child-sterility 
those  cases  in  which  a  woman  has  had  a  single  miscarriage,  and 
subsequently  remained  sterile,  since  by  this  miscarriage  the  capacity 
of  the  woman  for  impregnation  has  been  proved,  and  the 
question  of  capacity  for  full-term  delivery  has  nothing  to  do  with 
that  of  capacity  for  conception.  As  causes  of  this  form  of  sterility, 
they  lay  especial  stress  upon  puerperal  infection,  gonorrhoeal  infec- 
tion, perimetritis,  tubo-ovariah  tumours,  etc. 

Operative   Sterility. 

Finally,  in  order  to  complete  the  etiologically  classified  series  of 
forms  of  sterility,  we  must  allude  to  yet  another  variety  of  sterility 
which  is  due  to  the  surgical  direction  of  modern  gynecology,  viz., 
operative  sterility.  However  much  we  may  prize  the  gains  we  owe 
to  modern  operative  gynecology,  it  cannot  be  denied  that  the  new 
developments  have  brought  many  evils  in  their  train.  Not  the  least 
of  these  is  operative  sterility,  due  to  operative  procedures  involving 
the  female  reproductive  organs,  by  which,  whether  intentionally  or 
unintentionally  the  reproductive  capacity  is  destroyed.  Doubtless, 
in  certain  severe  organic  diseases  of  the  female  reproductive  ap- 
paratus, in  which  the  use  of  the  knife  is  indicated,  the  fact  that  by 
operating  we  are  sterilizing  the  patient  cannot  even  be  taken  into 
consideration ;  but  many  sins  have  been  committed  in  this  kind,  and 
writh  a  ready  hand,  and,  be  it  openly  admitted,  with  an  easy  con- 
science, many  an  eager  operator  has  undertaken  the  destruction  of 
a  woman's  potentialities  for  motherhood,  without  having  given  the 


564  THE  SEXUAL  LIFE  OF  WOMAN. 

careful  consideration  that  is  demanded  by  the  irreparable  character 
of  his  undertaking.  Happily,  however,  the  time  has  nearly  passed 
away,  in  which  it  could  be  said  of  many  a  gynecelogist,  that  no 
ovaries  and  no  Fallopian  tubes  were  safe  from  his  operative  zeal, 
and  from  his  desire  to  heap  up  a  mountain  of  statistics. 

Three  operative  measures  very  commonly  undertaken  at  the 
present  day  are  responsible  for  the  production  of  operative  sterility : 
ovariotomy,  oophorectomy,  and  salpingotomy. 

The  removal  of  the  ovaries,  with  the  object  of  permitting  to  the 
women  concerned  unbridled  sexual  indulgence  without  risk  of  con- 
sequences, was  performed,  according  to  Strabo,  by  the  ancient  Egyp- 
tians and  Lydians.  The  same  practice  is  described  by  modern 
writers  as  occurring  in  Hindostan  (Roberts),  and  in  Australia 
(Mikhtcho-Mackay). 

With  a  curative  aim,  the  removal  of  the  ovaries  was  first  under- 
taken in  the  early  years  of  the  nineteenth  century,  although  the 
operation  had  already  been  discussed  as  a  possibility  by  leading 
physicians  of  the  eighteenth  century.  The  first  ovariotomy  for  the 
removal  of  an  overian  tumour  was  performed  by  MacDo-wcll  in  the 
year  1809.  During  the  last  three  or  four  decades,  the  operation  has 
become  an  extremely  common  one,  and  is  performed  by  the  sur- 
geons of  all  nations.  Removal  of  a  single  ovary,  as  long  as  the  other 
ovary  is  healthy,  does  not  necessarily  lead  to  any  impairment  of 
fertility ;  but  when  both  ovaries  are  removed,  operative  sterility  is 
the  necessary  result.  In  order  to  avoid  this,  Schroder  has  recom- 
mended that  a  fragment,  at  least,  of  healthy  ovarian  tissue  should 
be  left  behind,  in  order  to  preserve  the  reproductive  capacity.  In 
discussing  the  subject  of  impaired  ovulation,  we  have  already  men- 
tioned cases  in  which  pregnancy  has  occurred  after  bilaterial  re- 
moval of  the  ovaries,  a  circumstance  explicable  only  on  one  of  two 
assumptions,  either  that  a  fragment  ovarian  tissue  was  left  behind, 
or  else  that  a  supernumary  ovary  existed. 

The  extirpation  of  healthy  ovaries,  or  at  any  rate,  of  ovaries 
which  are  not  notably  enlarged,  is  known  as  oophorectomy  (spay- 
ing, Battey's  operation,  in  Germany,  castration).  It  dates  from  the 
year  1869  (Koeberle)  ;  but  in  the  strictly  modern  sense  the  opera- 
tion was  first  performed  by  Hegar  in  the  year  1872.  [Lawson  Tail 
removed  both  ovaries  for  pain  in  October,  1871.  Battey's  first  opera- 
tion of  this  kind  was  successfully  performed  on  August  I7th,  1872; 
this  was  three  weeks  subsequent  to  the  first  performance  of  the 
operation  by  Hegar  of  Freiburg.  But  Hega/s  patient  died  from 
the  operation,  and  Hccjar  did  not  publish  the  case  at  the  time  — 
Transl.]  The  aim  of  ovariotomy  is  to  remove  an  ovarian  cystoma; 
if  the  other,  apparently  healthy,  ovary  is  removed,  it  is  with  the 
object  of  removing  an  ovarian  tumour  in  the  initial  stage.  Oopho- 


THE  SEXUAL  EPOCH  OF  THE  MENACME.  565 

rectomy  has  an  altogether  different  purpose,  namely,  to  relieve  or 
cure  pathological  manifestations  in  other  organs  which  are  believed 
to  depend  on  the  periodical  recurrence  of  ovulation,  to  cure  them  by 
instituting  a  premature  menopause.  At  one  period,  when  over- 
zealous  operators  performed  oophorectomy  for  the  supposed  relief 
of  comparatively  unimportant  nervous  affections,  and  the  statistics 
of  the  operation  began  to  assume  gigantic  proportions,  operative 
sterility  actually  came  to  play  no  inconspicuous  part  on  the  stage  of 
sterility  in  general.  But  a  reaction  inevitably  followed ;  severe 
diseases  were  alone  considered  as  furnishing  sufficient  indications 
for  the  operation ;  of  late  it  has  been  performed  chiefly  in  cases  in 
which  the  primary  disorder  has  already  rendered  the  occurrence  of 
pregnancy  impossible,  or  at  any  rate  very  unlikely,  or,  finally,  if 
probable,  yet  to  be  avoided,  on  account  of  the  dangers  it  would  en- 
tail. In  short,  the  fertility  of  women  is  no  longer  seriously  threat- 
ened by  this  operation. 

Some  .years  ago,  I  was  consulted  by  a  beautiful  married  woman, 
26  years  of  age,  of  a  blooming  and  healthy  aspect.  When  a  young 
girl,  she  had  suffered  every  month  at  the  time  of  the  menstrual 
flow  from  violent  vomiting,  accompanied  by  various  spasmodic 
troubles.  Just  at  this  time,  oophorectomy  was  the  fashionable  oper- 
ation for  the  relief  of  nervous  troubles;  this  girl  was  subjected  to 
the  operation,  and  the  vomiting  at  the  periods  ceased,  but  the  other 
nervous  symptoms  persisted  without  alleviation  —  indeed  were  at 
times  worse  than  before.  Since  then,  she  had  married  a  man  be- 
longing to  the  upper  circles  of  society ;  and  now,  after  living  for 
four  years  in  sterile  wedlock,  she  came  to  me  to  ask  my  advice  as  to 
whether  anything  could  be  done  to  enable  her  to  have  a  child !  Two 
other  cases  have  come  within  my  own  knowledge,  in  which  women 
whose  ovaries  had  been  removed  on  account  of  nervous  troubles, 
had  subsequently  married,  and  felt  most  unhappy  owing  to  their 
hopeless  state  of  sterility. 

It  is  impossible  to  make  even  an  approximite  estimate  of  the  num- 
ber of  women  who  in  recent  years  have  had  their  ovaries  removed 
during  the  period  of  sexual  maturity,  and  who  have  thus  been  made 
the  subjects  of  operative  sterility ;  nor  is  it  possible  to  ascertain  in 
what  proportion  of  cases  the  healthy  ovaries,  the  normal  female 
reproductive  glands,  have  been  removed  for  the  problematical  re- 
lief of  nervous  troubles  or  of  uterine  haemorrhage,  and  in  what 
proportion  of  cases  there  has  existed  a  genuine  indication,  owing  to 
the  presence  of  fibromyoma  of  the  uterus,  for  the  induction  of  an 
artificial  and  premature  menopause.  Unquestionably,  the  number 
of  women  thus  operated  on  during  the  menacme  is  by  no  means  a 
small  one.  In  a  work  by  Hermes,  "  On  the  Results  of  Oophorec- 
tomy in  Cases  of  Myoma  of  the  Uterus,"  Archiv  fur  Gynecologic, 


566  THE  SEXUAL  LIFE  OF  WOMAN. 

1894,  we  find  that,  among  55  women  whose  ovaries  were  removed 
on  account  of  myoma  of  the  uterus,  there  were  52  who  were  between 
the  ages  of  21  and  45,  i.  e.,  in  the  period  of  sexual  maturity.  The 
assumption  that  all  these  patients  were  already  sterile  before  the 
operation,  on  account  of  a  degenerate  condition  of  the  uterine  an- 
nexa,  cannot  be  justified. 

Kcpplcr,  indeed,  puts  forward  a  very  remarkable  defence  of 
the  removal  of  the  ovaries  of  women  who  are  competent  to  become 
mothers,  asserting  that  such  oophorectomy  offers  no  obstacle  to 
marriage,  and  that  many  women  who  have  been  operated  on  in  this 
manner  are  extremely  happy  in  conjugal  life.  Marriage  with  a 
wife  whose  ovaries  have  been  removed  is  the  ideal  Malthusian 
marriage,  the  one  way  in  which  Malthusianism  can  be  practised 
without  endangering  the  health  and  life-happiness  of  the  partici- 
pators ! 

Another  danger  soon  appeared,  one  which  threatened  the  fertility 
of  women  to  an  even  greater  extent,  in  the  form  of  operations  on  the 
uterine  annexa  —  the  first  salpingotomy  was  performed  by  He  gar 
in  1877.  As  knowledge  advanced  of  the  various  diseases  of  the 
Fallopian  tubes,  salpingitis,  hydrosalpinx,  and  pyosalpinx,  whilst  at 
the  same  time  the  development  of  the  antiseptic  method  rendered 
operative  gynecology  continually  bolder  and  bolder  in  its  under- 
takings, there  was  disclosed  an  extensive  field  for  radical  measures 
in  removal  of  the  tubes,  generally  combined  with  removal  of  the 
ovaries,  since  these  latter  organs  commonly  were  found  to  have 
suffered  from  association  in  the  destructive  inflammatory  process. 
The  operation  of  salpingo-oophorectomy  soon  became  a  very  com- 
mon one;  and  since  patients  with  diseased  tubes  are  for  the  most 
part  still  comparatively  young,  in  the  period  of  sexual  maturity, 
there  arose  a  new  and  frequent  variety  of  operative  sterility,  and 
one  which  the  zeal  of  American  gynecologists  made  especially  com- 
mon on  the  other  side  of  the  Atlantic.  An  American  gynecologist, 
indeed,  has  sarcastically  observed  that  "  It  is  the  dish-full  of  excised 
tubes  that  shows  the  master  gynecologist " ;  and  Landau  has  been 
impelled  to  lament  that  "  salpingotomy  has  been  performed  on  a 
very  large  number  of  women  who  have  complained  of  nothing 
more  serious  than  uterine  haemorrhages,  or  of  insignificant  pains, 
and  even  on  some  women  who  have  come  to  the  gynecologist  with 
no  other  complaint  than  that  —  they  are  sterile"!  Fritsch,  also. 
writing  of  the  too  rapidly  formed  diagnosis  "  tumor  of  the  annexa," 
and  the  consequent  resort  to  operation,  remarks :  "  I  know  many 
a  happy  mother  who  at  one  time  had  worn  every  variety  of  pessary, 
had  been  through  every  kind  of  '  cure,'  and  had  visited  every  access- 
ible spa ;  until,  at  last,  she  came  to  consult  me,  with  the  express  wish 
to  have  her  ovaries  removed.  Latterly,  she  had  been  advised  to  this 


$6; 

course  by  every  physician  she  had  consulted.  I  agreed,  in  such 
cases,  to  perform  the  operation,  with  the  stipulation  that  first  of  all, 
for  the  space  of  an  entire  year,  the  patient  should  not  see  a  single 
doctor,  should  visit  no  spa,  should  take  no  medicine,  and,  in  short, 
should  pay  no  attention  whatever  to  her  health.  The  success  of  this 
course  of  '  treatment '  was  often  extraordinary.  As  soon  as  the 
reproductive  organs  were  left  in  peace,  recovery  ensued."  The 
conservative  tendencies  of  the  surgery  of  the  last  decade,  have  mani- 
fested themselves  also  in  the  department  of  gynecology,  for  the 
happy  protection  of  woman  and  her  reproductive  capacity.  Oper- 
ative measures  are  now  commonly  restricted  to  the  relief  of  certain 
severe  forms  of  disease  of  the  uterine  annexa ;  in  cases  of  chronic 
inflammation  of  the  annexa,  the  surgeon  often  contents  himself  with 
dividing  or  breaking  down  the  adhesions,  and  leaves  the  organs  in 
situ ;  even  in  cases  of  bilateral  disease,  one  tube  only  may  be  re- 
moved; whilst  in  the  most  recent  method  of  all,  after  opening  the 
abdomen,  and  separating  the  pelvic  organs  from  their  adhesions, 
an  aperture  is  made  in  the  closed  tube,  and  this  artificial  ostium  is 
brought  into  apposition  with  the  ovary  by  the  insertion  of  sutures. 
In  a  word,  surgeons  have  come  to  realize  that  they  havte  in  the 
past  been  too  ready  to  sterilize  their  patients  by  the  performance  of 
double  salpingo-oophorectomy,  and  are  much  more  reluctant  than 
formerly  to  sacrifice  the  ovaries  and  the  Fallopian  tubes. 

Porro's  operation  is  another  cause  of  operative  sterility,  excision 
of  the  ovaries  being  combined  with  the  partial  excision  of  the  uterus, 
whereas  sterility  was  seldom  the  consequence  of  the  older  method  of 
Caesarian  section.  Indeed,  Porro's  operation  has  been  extolled  pre- 
cisely on  this  account,  that,  indicated  as  it  is  for  the  relief  of  ex- 
tremely difficult  labour,  it  renders  it  impossible  for  the  same  diffi- 
culty and  danger  ever  to  recur. 

The  classical  operation  of  Caesarian  section,  if  the  patient  makes 
a  favourable  recovery,  does  not  involve  sterility,  unless  in  very  ex- 
ceptional cases  (as  in  one  described  by  Lecluyse,  in  which,  after  the 
Caesarian  section,  a  communication  persisted  between  the  uterine 
cavity  and  the  cavity  of  the  abdomen,  through  which  the  semen 
passed  during  coitus).  Occasionally,  also,  in  performing  the  older 
operation,  the  operator  has  thought  it  right  to  prevent  the  future 
recurrence  of  pregnancy  by  adding  an  oophorectomy  to  the  primary 
operation. 

Pregnancy  and  parturition  are  still  possible  after  the  healing  of 
spontaneous  or  traumatic  ruptures  of  the  uterus ;  but  it  must  be  re- 
membered that  after  such  serious  injuries,  as  after  extensive  opera- 
tive procedures  on  the  pelvic  organs,  widespread  peritoneal  inflam- 
mation is  apt  to  occur,  with  perimetritic  and  parametritic  exuda- 
tions, leading  commonly  to  sterility. 


568  THE  SEXUAL  LIFE  OF  WOMAN. 

Amputation  of  the  vaginal  portion  of  the  cervix,  an  operation 
sometimes  undertaken  for  the  relief  of  sterility  in  cases  of  hyper- 
trophy of  the  cervix,  may  on  the  other  hand  lead  to  sterility  in 
cases  in  which  a  cicatricial  stenosis  of  the  cervical  canal  results 
from  the  operation. 

By  the  too  frequent  application  of  caustics  to  the  cervical  canal, 
or  by  the  employment  of  these  agents  in  too  powerful  a  form,  oc- 
clusion of  the  os  externum  may  be  caused,  or  even  adhesion  of  the 
opposing  walls  of  the  vagina  just  below  the  cervix,  thus  giving  rise 
to  sterility.  Rough  use,  also,  of  the  uterine  sound,  and  maladroit 
and  violent  gynecological  massage,  have  often  enough  been  respon- 
sible for  the  occurrence  of  sterility,  by  giving  rise  to  perimetritic 
inflammation.  La;  dau  enumerates  among  the  causes  of  intra-pelvic 
abscesses,  "  whereby  the  specific  functions  of  womanhood  are  nulli- 
fied in  consequence  of  degeneration  of  the  tubes  or  the  ovaries," 
"  certain  therapeutic  procedures,"  and  more  especially,  intra-uterine 
therapy,  (the  use  of  the  sound,  curettage,  injections,  cauterization), 
and  operations  on  the  cervix  or  the  vagina,  on  which  intra-pelvic 
inflammation  and  even  suppuration  has  ensued.  How  easily  pelvic 
peritonitis  and  its  consequences  lead  to  sterility  in  women,  has  been 
shown  many  times  in  the  course  of  our  exposition  of  this  subject. 

Finally,  we  must  class-  with  operative  sterility  the  result  of  sur- 
gical procedure  undertaken  by  gynecologists  to  save  women,  whose 
lives  have  already  been  seriously  threatened  by  pregnancy  or  par- 
turition, from  a  repetition  of  this  experience.  In  such  cases,  Blun- 
dcll  recommends  division  of  the  Fallopian  tubes,  having  found 
from  experiments  upon  rabbits  that  this  is  a  safe  and  certain 
means  for  the  prevention  of  conception.  Frorieps  and  Kocks  have 
both  frequently  brought  about  an  artificial  sterility  in  women  by 
closure  of  the  tubes,  the  first-named  by  cauterization  with  nitrate  of 
silver  —  the  caustic  being  attached  to  the  end  of  a  piece  of  whale- 
bone and  introduced  through  a  canula  into  the  uterine  orifice  of  the 
Fallopian  tube  —  whilst  Kocks  has  constructed  for  the  same  pur- 
pose a  galvano-caustic  uterine  sound,  which  is  only  rendered  Fed-hot 
by  passage  of  the  current  after  it  has  been  introduced  into  the 
uterine  ostium  of  the  tube.  Both  these  methods  are  in  the  first 
place  too  uncertain  to  be  relied  upon  for  the  attainment  of  the* 
desired  end,  and  in  the  second  place  their  employment  appears  to 
be  neither  easy,  nor  free  from  danger. 

As  the  importance  of  conservative  methods  of  procedure  becomes 
once  more  fully  recognized  in  modern  gynecology,  cases  of  operative 
sterility  will  become  ever  more  and  more  rare. 


THE  SEXUAL  EPOCH  OF  THE  MENACME. 


569 


TABLE  SHOWING  THE  CAUSES  OF  STERILITY  IN  WOMEN. 
I.  STERILITY  DUE  TO  INCAPACITY  FOR  OVULATION. 


ABSOLUTE  AND  IRREMEDIABLE. 

Complete  absence  of  the  ovaries. 

Congenital  atrophy  of  both  ovaries. 

Premature  atrophy  of  the  ovaries,  in 
consequence  of  infectious  disorders, 
constitutional  diseases,  and  toxic 
influences. 

New-growths  of  the  ovaries,  destroy- 
ing all  the  follicles. 

Senile  changes  in  the  ovaries. 

Complete  oophorectomy,  or  any 
equivalent  form  of  operative  steril- 
ity. 


RELATIVE  AND  TRANSIENT. 

Incomplete  development  of  the 
ovaries. 

Imperfect  formation  of  ova,  owing  to 
marriage  when  still  too  young 
(amenorrhoea). 

Ovarian  tumours  and  oophorectomy, 
whereby,  however,  a  remnant  of 
healthy  ovarian  tissue  is  spared. 

Chronic  opphoritis  and  perioophoritis  ; 
syphilitic  disease  of  the  ovaries. 

Excessive  obesity,  anaemia,  chlorosis, 
scrofula,  morphinism,  alcoholism, 
various  conditions  affecting  un- 
favourably the  innervation  or  nutri- 
tion of  the  ovary  change  of  climate 
or  mode  of  life ;  emotional  disturb- 
ance ;  inbreeding,  hereditary  pre- 
disposition. 


II.  STERILITY  DUE  TO  INTERFERENCE  WITH  THE  CONTACT  OF  NORMAL 
SPERMATOZOON  AND  OVUM. 

A.  On  the  Part  of  the  Wife. 


ABSOLUTE  AND  IRREMEDIABLE. 

Congenital  or  acquired  universal 
thickening  of  the  tunica  albuginea 
of  the  ovaries,  preventing  the  de- 
hiscence  of  the  follicles. 

Absence  of  both  tubes,  developmental 
defects  of  these  organs. 

Absence  or  rudimentary  condition  of 
the  uterus.  Foetal  uterus. 

Congenital  atresia  of  the  uterus  with 
arrest  of  development. 

Complete  absence  of  the  vagina. 

Extreme  contraction  of  the  pelvis, 
whereby  the  vagina  is  rendered  in- 
accessible. 

Hcrmaphroditism. 


RELATIVE  AND  TRANSIENT 

Remediable  thickening  of  the  tunica 
albuginea,  inflammatory  remnants 
of  perioophoritic  processes,  diseases 
of  the  cervical  glands,  dislocations 
and  adhesions  of  the  tubes,  narrow- 
ing or  obliteration  of  the  ostia,  in- 
flammation of  the  tubes,  pyosalpinx, 
obliteration  of  the  lumen  -of  the 
tube. 

Retrouterine  haematocele. 

New  growths  in  the  uterine  cavity. 

Infantile  and  pubescent  uterus. 

Primary  atrophy  of  the  uterus. 

Puerperal  atrophy  of  the  uterus. 

Displacements  of  the  uterus  —  ver- 
sions and  flexions. 

Hypertrophy  or  atrophy  or  changes 
in  the  shape  of  the  cervix,  cervical 
stenosis. 

Cervical  catarrh,  especially  when  gon- 
orrhoeal. 

Ectropium  of  the  cervix. 

Spasmodic  dysmenorrhoea. 

Atresia  of  the  vagina,  obliteration  of 
the  canal  by  scars  or  tumours. 

Abnormal  termination  of  the  vagina 
—  vesico-vaginal  and  recto-vaginal 
fistula. 


57O  THE  SEXUAL  LIFE  OF  WOMAN. 

ABSOLUTE  AND  IRREMEDIABLE.  RELATIVE    AND    TRANSIENT. 

Absence  of  the  external  organs  of 
generation  and  partial  absence  of 
the  vagina,  without  defect  of  the 
internal  organs  of  generation. 

Abnormalties  of  the  hymen. 

Pathological  states  of  the  genital  se- 
cretions. 

Vaginismus. 

Dyspareunia. 

Perversion  of  the  sexual  impulse. 

B.  On  the  Part  of  the  Husband. 

ABSOLUTE  AND  IRREMEDIABLE.  RELATIVE  AND  TRANSIENT. 

Diseases  of  the  central  nervous  sys-  Developmental   defects  of  the  penis, 

tern,  and  certain  constitutional  dis-  and    acquired    deformities   of    that 

eases.  organ. 

Congenital    or    acquired    absence    of  Stricture  of  the  urethra. 

both  testicles.  Oligozoospermia. 

Atrophy  of  the  testicles.  Nervous  impotence. 

Complete  azoospermia  and  asperma-  Gonorrhoeal  and  syphilitic  infection. 

tism.  The  employment  of  measures  for  the 

Senile  impotence.  prevention  of  pregnancy    (faculta- 
tive sterility). 

III.  STERILITY  DUE  TO  INCAPACITY  FOR  THE  IMPLANTATION  AND  FURTHER 
DEVELOPMENT  OF  THE  OVUM. 

ABSOLUTE  AND  IRREMEDIABLE.  RELATIVE  AND  TRANSIENT. 

Arrested  development  of  the  uterus.         Chronic  metritis. 
Complete     atrophy     of     the     uterine       Chronic  endometritis,  especially  gon- 
mucous  membrane.  orrhoeal    and    exfoliative    endome- 

tritis. 

Perimetritis,  parametritis,  pelvic  per- 
itonitis ;  the  consequences  of  these 
inflammations. 
Tumours  of  the  uterus. 
Displacements  of  the  uterus. 


III.  SEXUAL  EPOCH  OF  THE  MENOPAUSE. 


THE  MENOPAUSE. 

That  time  in  a  woman's  life  at  which  her  sexual  activities  come 
to  their  natural  termination,  marked  by  the  cessation  of  menstrua- 
tion, is  known  as  the  menopause,  climax,  or  climacteric  period. 

This  "  change  of  life,"  from  a  condition  of  sexual  maturity  to  a 
condition  of  quiescence  of  sexual  functions,  is  not  a  sudden  one, 
the  symptoms  of  sexual  retrogression  making  their  appearance  grad- 
ually, until  the  cessation  of  the  monthly  recurring  menstrual  flow 
indicates  that  the  termination  of  sexual  activity  has  arrived,  and 
that  sexual  death  is  taking  place. 

The  influence  of  this  period  of  life  is  not  manifested  by  the  sexual 
organs  alone  —  in  these  latter  indeed  various  changes  may  be  de- 
tected already  before  the  cessation  of  menstruation,  whilst  after  that 
cessation,  the  atrophic  changes  characteristic  of  old  age  proceed  in 
these  organs  with  a  slow  but  continuous  advance, —  but  the.  dis- 
turbances evoked  by  the  climacteric  involve  the  entire  organism  and 
affect  the  functions  of  numerous  organs,  giving  rise  to  a  true  storm 
of  irritant  phenomena,  and  to  manifestations  of  decay  of  manifold 
nature. 

The  stormy  manifestations,  the  occurrence  of  which  led  the 
ancients  to  denote  this  period  as  the  "  critical  age  "  of  a  woman's 
life,  are  in  the  first  place  due  to  changes  in  the  ovaries;  the  tissue 
changes  in  these  organs  give  rise  to  a  powerful  ovarian  stimulus, 
which,  by  irradiation  and  reflex  action,  leads  to  the  occurrence  of 
a  number  of  nervous  disturbances,  vaso-motor  manifestations,  and 
circulatory  disorders ;  whilst  owing  to  the  cessation  of  the  internal 
secretions  of  the  ovaries,  numerous  and  intense  pathological  dis- 
orders of  metabolism  arise.  These  various  symptoms  become  ap- 
parent at  the  very  outset  of  the  menopause,  when  the  oncoming 
entire  cessation  of  menstruation  is  already  foreshadowed  by  irreg- 
ularity in  the  periods,  gradual  diminution  in  the  quantity  of  the 
flow,  and  variations  in  the  number  of  days  during  which  the  flow 
on  each  occasion  persists. 

The  manifestations  of  the  menopause  are  in  fact  so  striking,  that 
from  ancient  times  down  to  the  present  day  a  widespread  belief  has 
prevailed  that  especial  danger  to  a  woman's  life  is  threatened  by 


572  THE  SEXUAL  LIFE  OF  WOMAN. 

the  climacteric  age.  The  statistics  available  on  this  subject  are, 
however,  of  dubious  significance.  Although  it  cannot  be  denied 
that  the  changes  in  the  entire  organism  which  attend  the  extinc- 
tion of  sexual  activity,  bring  numerous  dangerous  influences  into 
play,  yet  I  feel  bound  to  maintain  that  these  dangers  are  by  no 
means  so  great  as  those  which  are  involved  by  the  sexual  life  in  its 
ripest  period  of  development  —  the  dangers  of  pregnancy,  parturi- 
tion, and  the  puerperium. 

It  is  often  asserted  that  in  this  "  critical  period  "of  the  meno- 
pause, the  mortality  of  the  female  sex  is  notably  increased.  The 
data  available  are  somewhat  conflicting,  but  a  careful  examination 
leads  us  to  believe  that,  if  due  allowance  is  made  for  the  natural 
increase  in  mortality  with  advancing  years,  no  important  increase  in 
the  mortality  of  women  can  be  traced  as  due  to  the  troubles  and 
disturbances  of  the  climacteric  period. 

The  age  at  which  a  woman's  last  sexual  epoch  begins  is  a  very 
variable  one.  The  duration  of  the  "  change  of  life,"  the  length  of 
time  during  which  the  occurrence  of  the  "  change  "  is  manifested 
by  local  and  general  disturbances,  also  varies  greatly.  Not  less 
variable  are  the  intensity  and  the  general  distribution  of  the  symp- 
toms which  mark  the  climacteric. 

The  external  configuration  of  woman  at  the  climacteric  age  is 
usually  characterized  by  signs  of  over-ripeness,  and  these  changes 
appear  to  exercise  upon  certain  men  —  more  especially  very  young 
men  —  a  peculiar  kind  of  erotic  stimulus.  Many  women  remain 
long  at  this  period  quite  fresh  looking,  with  a  vivid,  youthful  col- 
ouring; others,  however,  early  manifest  alterations  in  their  finer 
feminine  characteristics,  hairs,  for  instance  sprouting  on  the  chin, 
and  the  voice  becoming  deeper  in  tone. 

The  outward  characters  of  senescence,  with  withering  of  the 
tissues,  are  not  commonly  manifested  at  this  time,  but  first  make 
their  appearance  in  later  years,  after  the  completion  of  the  meno- 
pause. 

A  tendency  to  the  excessive  accumulation  of  fatty  tissue  is  one 
of  the  most  distinctive  characteristics  of  the  menopause,  varying, 
however,  greatly  in  degree  according  to  race,  family  predisposition, 
and  nutritive  conditions.  The  dominant  tone  is  thus  given  to  the 
physical  configuration  by  the  deposit  of  fat.  The  face  comes  to 
have  a  rounded,  spherical  appearance,  the  eyes,  looking  smaller  in 
proportion,  whilst  the  furrows  and  folds  which  form  the  natural 
boundaries  between  the  features  become  indistinct.  The  formation 
of  the  "  double  chin,"  and  the  abundant  deposit  of  fatty  tissue  in 
the  supraclavicular  region,  gives  to  these  extremely  obese  women 
an  appearance  of  such  a  shortening  of  the  neck,  that  head  and 
thorax  seem  to  be  connected  as  it  were  by  a  great  mass  of  fat, 


SEXUAL  EPOCH  of  THE  MENOPAUSE.  573 

marked  by  furrows  in  the  thyroid  and  sub-hyoid  regions.  The 
breasts  sometimes  attain  an  enormous  size,  hanging  down  to  the 
gastric  and  even  to  the  umbilical  region.  The  abdomen  is  greatly 
enlarged,  the  fat  in  the  anterior  abdominal  wall  projecting  more 
especially  in  the  hypogastric  region,  hanging  down  in  two  or  three 
horizontal  rolls  over  the  tops  of  the  thighs,  and  pushing  the  mons 
veneris  downwards,  so  that  this  latter  itself  projects  over  the  genital 
fissure.  The  posterior  projection  of  the  buttocks  is  also  greatly  in- 
creased, until  they  form  a  huge  elastic  cushion,  of  which  the  sen- 
sual orientals,  who  regard  obesity  in  women  as  a  beauty,  poetically 
write :  "  Her  face  is  like  the  full  moon,  and  her  buttocks  are  like 
two  pillows."  Occasionally,  so  huge  a  mass  of  fat  forms  beneath 
the  tuberosity  of  the  ischium,  that  the  configuration  of  the  nates 
reminds  us  of  the  well-known  steatopyga  or  fat-rump  of  the  Hot- 
tentot and  Bosjesman  women.  In  the  genital  organs,  as  already 
mentioned,  the  genital  fissure  is  hidden  by  the  projection  of  the 
mons  veneris.  The  labia  majora  are  also  greatly  enlarged  by 
the  deposit  of  fat,  so  that  they  look  like  two  great  cylinders  lying 
side  by  side.  Another  way  in  which  the  characteristic  sexual 
beauty  is  often  lost  in  extremely  obese  women,  is  by  the  falling  out 
of  the  pubic  hair. 

Morcan,  in  his  work  on  The  Natural  History  of  Woman,  describes 
the  changes  occurring  in  a  woman  at  the  climacteric  in  similar  terms, 
and  concludes :  "  The  only  elements  of  a  woman's  beauty  that  may 
sometimes  be  saved  from  the  wreck,  to  persist  for  a  shorter  or 
longer  time  after  the  climacteric,  are,  the  abundance  of  her  hair,  the 
vivacity  of  her  glance,  and  sometimes  also  the  amiable  expression  of 
her  countenance ;  gradually,  however,  even  these  last  remnants  of 
beauty  disappear,  and  old  age  takes  possession  with  its  irresistible 
force." 

None  the  less,  some  women  may  preserve  substantial  elements  of 
beauty  for  a  long  time  after  the  menopause.  A  classical  ex- 
ample of  this  fact  is  furnished  by  Ninon  de  I'Enclos.  When  she 
died,  at  the  age  of  90,  she  was  still  beautiful.  At  the  age  of  65  she 
aroused  the  passionate  love  of  a  young  man,  who,  unfortunately, 
was  her  own  son.  When  informed  of  this,  he  committed  suicide. 
A  young  abbe  fell  in  love  with  her  when  she  was  75  years  old. 

The  psychical  life  of  woman  is  profoundly  affected  by  the  stormy 
physical  changes  of  the  climacteric.  Not  merely  does  a  woman 
entertain  the  disturbing  thought  that  the  critical  age  has  begun, 
bringing  in  its  train  certain  dreaded  dangers  to  her  health  and  even 
her  life,  but  she  is  further  depressed  by  the  consciousness  that  she 
is  about  to  lose  her  feminine  attractions,  and  to  decline  in  sexual 
esteem,  and  that  her  reproductive  capacity  is  now  to  be  extinguished. 
She  realizes  vividly  that  the  beautiful  past,  the  loving  and  beloved 


574  THE  SEXUAL  LIFE  OF  WOMAN. 

womanhood,  is  now  to  be  left  behind  for  ever,  and  by  this  an  intel- 
ligent and  sensitive  woman  cannot  fail  to  be  profoundly  affected. 
Her  feelings  at  this  time  were  never  more  characteristically  ex- 
pressed than  by  the  Frenchwoman  who  said  "  Autrefois  quand 
j'etais  femme."  If,  indeed,  a  woman  has  been  so  fortunate  as  to 
have  made  a  happy  marriage,  to  have  borne  healthy  children,  and 
to  be  living  a  satisfactory  family  life,  she  will  be  enabled  to  bear 
with  comparative  equanimity  the  disappearance  of  her  sexual  life; 
but  it  is  different  with  the  childless  wife  and  with  the  unmarried 
woman,  who,  at  the  onset  of  the  climacteric,  must  bury  all  their 
sexual  aspirations,  and  who  see  the  remainder  of  their  lives  stretch 
before  them  without  hopes  for  the  future.  The  psychical  predis- 
position and  the  intellectual  education  of  the  woman  concerned, 
will  now  determine  whether  she  will  bear  the  onset  of  the  meno- 
pause with  composure  and  resignation,  or  whether  she  will  become 
a  prey  to  melancholia.  Women  of  the  former  kind  will  seek  to  find 
employment  for  the  powers  set  free  by  their  sexual  non-activity,  in 
services  of  neighbourly  affection,  in  works  of  benevolence,  and  in 
the  performance  of  social  duties;  women  less  happily  endowed  will 
display  their  hostility  to  the  world  in  ill-nature,  scandal-mongering, 
and  intrigue,  thus  giving  vent  to  their  inward  bitterness ;  whilst 
those,  finally,  with  hereditary  predisposition  to  nervous  degenera- 
tion, will  become  the  prey  of  veritable  psychoses. 

A  by  no  means  rare  result  of  the  excited  fantasy  and  of  the  eager 
desire  not  to  grow  old,  is  displayed  at  the  climacteric  in  the  form  of 
self-deception.  The  women  thus  affected  cannot  understand,  and 
cannot  be  made  to  believe,  that  the  cessation  of  menstruation  is  the 
natural  sign  of  their  sexual  decadence,  they  trick  themselves  into 
believing  that  in  their  case  it  is  a  sign  that  they  have  become  preg- 
nant. We  must  not  indeed  forget  that  the  enlargement  of  the 
abdomen,  so  common  at  the  commencement  of  the  climacteric,  in 
association  with  the  unexpected  failure  of  the  menstrual  flow  to 
appear,  the  frequent  dyspeptic  troubles,  and  the  enlargement  of  the 
breasts  in  consequence  of  the  deposit  of  fat  in  these  organs,  often 
enough  lead  to  appearance  which  have  a  deceptive  resemblance  to 
the  clinical  picture  of  early  pregnancy.  The  mistake  is  the  more 
readily  made  because  the  breasts  sometimes  secrete  a  serous  fluid, 
whilst  sacrache  is  not  infrequent,  and  peristaltic  movements  -of  the 
intestines  are  mistaken  for  the  movements  of  the  foetus.  Cases  of 
this  kind,  in  which  all  the  objective  signs  of  pregnancy  appear  to  be 
present,  and  in  which  it  is  impossible  to  convince  the  woman  that 
she  has  been  deceiving  herself,  and  that  all  the  signs  and  symptoms 
are  due  to  the  menopause,  are  mentioned  already  by  very  early 
writers,  and  have  been  frequently  reported  by  modern  gynecologists. 


SEXUAL  EPOCH  OF  THE  MENOPAUSE.  575 

(An  example  of  spurious  pregnancy  especially  familiar  to  English 
readers  is  that  of  Mary  I,  Queen  of  England.     Transl.) 

Sexual  desire  in  woman  by  no  means  reaches  its  physiological 
term  with  the  climacteric  and  the  cessation  of  menstruation.  On 
the  contrary,  we  have  observed  it  to  be  the  rule  that  shortly  before 
and  at  the  commencement  of  the  climacteric,  there  is  a  considerable 
increase  in  the  libido  sexualis,  and  at  the  same  time  an  increase  in 
sexual  sensibility  during  coitus.  This  sexual  erethism  makes  its 
appearance  in  a  manner  often  extremely  surprising  to  the  husband 
—  and  especially  surprising  in  the  case  of  women  who  have  pre- 
viously been  characterized  by  a  certain  frigidity  in  sexual  matters, 
and  who  have,  perhaps,  always  needed  strong  persuasion  before  they 
would  consent  to  perform  their  marital  duties.  It  is  by  no  means 
rare  for  the  increased  sexual  impulse  to  manifest  itself  in  some 
pathological  form.  Even  some  time  after  the  menopause,  when 
senile  changes  in  the  genital  organs  are  far  advanced,  the  sexual 
impulse  may  still  be  remarkably  active.  There  is  an  interesting 
analogy  in  the  fact  that  Glaevccke  observed  that  the  sexual  impulse 
was  persistent  in  women  in  whom  an  artificial  menopause  had  been 
induced  by  oophorectomy ;  and  that  Laivson  Tait  and  L.  Smith  have 
reported  cases  in  which  dyspareunia,  which  had  existed  prior  to  the 
operation,  passed  away  after  the  removal  of  the  ovaries,  so  that 
after  the  artificial  menopause,  voluptas  coeundi  for  the  first  time 
made  its  appearance.  Other  authors,  Goodell,  for  instance,  report 
that  libido  sexualis  is  retained  only  for  a  short  time  after  oophorec- 
tomy, but  subsequently  disappears,  as  in  the  course  of  the  physi- 
ological menopause,  and  that  at  the  same  time  the  voluptas  coeundi 
is  entirely  extinguished. 

When  the  menopause  is  fully  established,  and  the  processes  of 
involution  in  the  reproductive  organs  have  taken  place  in  a  normal 
manner,  the  woman  has  had  time  to  acquiesce  in  the  inevitableness 
of  the  changes  that  have  occurred,  and  she  often  attains  a  state  of 
emotional  repose  which  was  quite  unknown  to  her  in  the  earlier 
phases  of  her  sexual  life.  More  particularly,  those  women  who 
hitherto  during  menstruation,  and  for  some  days  before  and  after 
the  flow,  have  been  the  prey  of  numerous  nervous  symptoms  and 
troubles,  rejoice,  after  the  menopause,  at  their  new-won  freedom 
from  these  pains  and  disquiets,  at  their  delivery  from  the  excite- 
ment's of  the  reproductive  system,  at  their  now  uninterrupted  state 
of  well-being. 

I  once  saw  a  group  of  statuary  by  Pietro  Balestra,  entitled  "  Time 
carries  off  Beauty/'  A  beautiful  woman  was  striving  in  vain  to 
resist  the  overwhelming  might  of  Chronos,  whilst  Cupid,  about  to 
be  abandoned,  was  standing  sorrowfully  by.  Here  we  have  a  sym- 
bolic representation  of  the  sexual  epoch  of  the  menopause. 


576  THE  SEXUAL  LIFE  OF  WOMAN. 

In  a  recently  published  romance,  "Les  Demi-Vieilles,"  Yvette 
Guilbert  has  described  in  a  manner  most  true  to  nature  the  feelings 
of  the  "  Half-Old,"  the  mental  condition  of  women  at  the  climac- 
teric, "  They  endeavour  to  remain  young,  to  hide  their  defects,  they 
seek  once  again  the  intoxication  of  love.  But  that  which  aforetime 
in  hours  of  depression  they  have  foreseen,  now  becomes  a  dreadful 
reality.  When  the  lemon  has  been  squeezed  dry,  the  skin  is  thrown 
away." 

Sooner  or  later  after  the  completion  of  the  menopause,  the  signs 
of  senile  marasmus  become  apparent.  The  soft,  feminine  configura- 
tion of  the  face  disappears,  the  features  become  coarser,  approach- 
ing the  masculine  type,  hairs  appear  on  the  upper  lip  and  on  the 
chin.  The  voice  becomes  deeper  and  harsher.  As  decrepitude  be- 
gins, the  breasts  wither,  a  change  that  occurs  sooner  in  proportion 
to  the  degree  in  which  their  functions  have  been  in  previous  years 
exercised  by  suckling;  but  also  sometimes  after  a  life  of  complete 
sexual  inactivity.  Even  in  cases  in  which  the  loss  of  substance  of 
the  breasts  is  apparently  small,  the  glandular  tissue  of  the  organs 
has  really  disappeared,  and  has  been  replaced  by  fat.  In  advanced 
age,  the  breasts  become  quite  small,  wrinkled,  flaccid,  and  dependent, 
and  sometimes  atrophied  to  become  mere  cutaneous  folds.  The 
nipples  project  more  prominently,  they  are  darker  in  colour,  and 
their  surface  is  wrinkled.  In  the  genital  organs,  the  fat  disappears 
from  the  mons  veneris,  which  becomes  flattened,  whilst  the  pubic 
hair  ceases  to  be  curly,  and  much  or  all  of  it  is  ultimately  shed.  The 
labia  majora  become  thin  and  flaccid,  until  they  are  mere  empty 
folds  of  skin;  they  are  widely  separated,  so  that  the  vaginal  orifice 
is  closed  only  by  the  withered  nymphae,  until  these  latter  are  them- 
selves ultimately  indicated  by  mere  traces. 

Where  the  menopause  has  been  artificially  induced,  the  signs  of 
senescence  do  not  appear  immediately  after  the  removal  of  the 
ovaries;  their  development  is  a  very  gradual  one.  The  sexually 
mature  woman,  from  whom  these  tokens  of  femininity  have  been 
removed,  experiences  at  first  little  change  in  external  configur- 
ation, beyond  a  somewhat  exaggerated  tendency  .to  the  deposit  of 
fat ;  the  other  changes  described  do  not  usually  set  in  until  the 
physiological  climacteric  age  is  attained.  A  few  cases  only  have 
been  observed  in  which  after  oophorectomy  a  rapid  change  to  the 
masculine  configuration  has  been  observed. 

Seldom  if  ever  does  it  happen  that  menstruation  suddenly  ceases 
without  any  notable  constitutional  disturbance,  so  that  in  a  moment, 
as  it  were,  the  menopause  is  effected,  without  any  period  of  trans- 
ition. Rarely,  even,  do  we  meet  with  cases  in  which  the  peculiar 
manifestations  foreshadowing  or  accompanying  the  cessation  of 
menstruation  last  for  no  more  than  a  few  weeks.  Most  commonly 


SEXUAL  EPOCH  OF  THE  MENOPAUSE.  577 

the  irregularities  of  the  menstrual  function  (of  which  tht  most  note- 
worthy characteristic  has  hitherto  been  its  extreme  regularity),  and 
the  associated  symptoms  of  the  climacteric  period,  endure  for  months, 
and  occasionally  for  years.  According  to  my  own  observations,  the 
mean  duration  of  the  climacteric  manifestations  is  from  two  to  three 
years,  the  limits  of  Variation  in  individual  cases  being,  however, 
exceedingly  wide, 

The  manifestations  which  accompany  the  cessation  of  menstrua- 
tion are  as  a  rule  the  following:  The  woman  is  for  some  months 
in  an  irritable  condition,  complains  of  digestive  disturbances,  con- 
stipation, meteorism,  epistaxis,  haemorrhoidal  flux,  congestions  of 
the  head,  increasing  fugitive  sensations  of  heat  (Ger.  fliegende 
Hitze),  and  a  tendency  to  profuse  perspiration. 

The  length  of  the  intermenstrual  interval  commonly  increases, 
to  as  much  as  six  or  eight  weeks ;  the  flow  itself  becomes  scantier. 
In  other  cases,  however,  the  flow  becomes  much  more  abundant,  and 
the  intermenstrual  intervals  much  shorter  than  normal.  In  some 
cases,  the  regularity  of  the  flow  is  altogether  lost,  it  appears  now 
soon,  now  late,  and  is  now  scanty,  now  profuse.  Sometimes  the 
intervals  are  several  months,  it  may  be  6,  8,  arid  even  10  months, 
then  again  the  flow  will  occur  every  two  or  three  weeks ;  in  excep- 
tional cases,  a  scanty  flow  persists  right  through  what  should  be 
the  interval,  so  that  menstruation  becomes  continuous,  with  periodic 
increases  in  the  flow.  Not  infrequently,  after  a  sudden  cessation  of 
the  flow  lasting  for  many  months,  menstruation  recurs,  and  con- 
tinues at  regular  intervals  for  a  long  time,  until  the  final  cessation 
of  menstrual  activity. 

The  mode  of  cessation  which  is  most  favourable  to  a  woman's 
general  health,  is  for  the  duration  of  the  intermenstrual  interval 
gradually  to  increase,  whilst  pari  passu  with  this  increase,  the 
amount  of  the  flow  progressively  decreases,  until  it  ceases  altogether. 
In  such  cases,  the  general  constitutional  disturbance  is  reduced  to 
a  minimum.  On  the  other  hand,  the  sudden  cessation  of  menstrua- 
tion gives  rise  to  profound  disturbance  of  the  domestic  economy 
of  the  feminine  organism,  and  causes  violent  changes  therein.  But 
even  the  gradual  cessation  of  menstruation  causes  notable  disturb- 
ance of  the  woman's  mental  and  physical  equilibrium,  if  the  irregu- 
larities in  the  menstrual  process  are  very  great  and  spread  over  a 
very  long  period — more  especially  when  the  loss  of  blood  is  ex- 
tensive. 

Even  after  the  menopause,  after  the  final  termination  of  the  flow, 
there  persists  a  more  or  less  regular  recurrence  of  certain  symptoms 
referable  to  the  continuance  of  ovulation.  Sacrache,  a  sense  of 
abdominal  tension,  a  feeling  of  heat  and  fullness  in  the  pelvis, 
dragging  pain  in  the  hypogastrium,  and  general  irritability,  occur  at 

37 


578  THE  SEXUAL  LIFE  OF  WOMAN. 

intervals,  so  4hat  the  woman  thus  affected  sometimes  describes  her- 
self as  suffering  from  the  continuance  of  a  "  bloodless  menstrua- 
tion." 

Tilt  made  observations  in  637  women,  in  order  to  ascertain  the 
various  modes  in  which  the  menopause  occurs,  and  obtained  the 
following  results.  The  menopause  occurred: 

By  gradual  diminution  of  the  amount  of 

the  flow in  171  women,  or  26.84  per  cent. 

By  sudden  interruption  of  the  flow in  94  women,  or  14.76  per  cent. 

By  sudden  interruption  and  a  terminal 

attack  of  metrorrhagia  in  43  women,  or  6.75  per  cent. 

By  a  terminal  attack  of  metrorrhagia....  in  82  women,  or  12.87  per  cent. 
By  a  series  of  attacks  of  metrorrhagia.  ..  in  56  women,  or  8.79  per  cent. 
By  alternations  of  very  profuse  and  very 

scanty  menstruation  in  36  women,  or  5.65  per  cent. 

By  irregular  recurrence  of  menstruation, 

at  intervals  exceeding  21  days in  99  women,  or  15.54  Per  cent- 

By  irrgular  recurrence  of  menstruation,  at 

intervals  of  less  than  21  days in  33  women,  or  5.18  per  cent. 

By  irregular  recurrence  of  menstruation, 

the    intervals    being    sometimes    longer 

and  sometimes  shorter  than  21  days....     in   23  women,  or    3.61  per  cent. 

Totals : 637  99.99 

The  two  principal  dangers  of  the  climacteric  period  in  women  are, 
first,  the  great  tendency  to  profuse  uterine  haemorrhages,  and, 
secondly,  the  liability  to  the  occurrence  of  malignant  tumours,  more 
especially  to  carcinomatous  disease  of  the  ovaries,  the  uterus,  and  the 
mammae. 

With  regard  to  the  question  whether,  in  any  particular  individual, 
the  course  of  the  menopause  is  likely  to  be  favourable  or  unfavour- 
able, there  are,  in  my  experience,  four  considerations  of  principal 
prognostic  significance:  the  condition  of  the  woman  during  the 
menarche,  the  state  of  the  general  health  at  the  time  of  commence- 
ment of  the  menopause,  the  degree  to  which  the  sexual  functions 
have  been  and  are  being  exercised,  and  the  manner  in  which  the 
cessation  of  menstruation  takes  place. 

As  a  rule,  the  disturbances  and  pathological  states  of  the  climac- 
teric period  will  be  especially  frequent  and  severe  in  women  whose 
sexual  development  at  the  time  of  the  menarche  was  accompanied 
by  severe  disturbances  of  the  general  condition.  In  every  individ- 
ual, there  appears  to  be  a  certain  connexion  between  the  manifesta- 
tions attending  the  menarche  and  those  attending  the  menopause, 
of  such  a  nature  that  according  as  puberty  has  been  passed  through 
with  little  or  with  much  disturbance  of  the  general  condition,  a 
similar  favourable  or  unfavourable  course  of  the  menopause  may 
be  prognosticated.  If,  at  the  time  of  the  menarche,  there  were 
severe  nervous  manifestations,  or  heart  troubles  of  a  serious  kind, 


SEXUAL  EPOCH  OF  THE  MENOPAUSE.  579 

the  passage  of  the  menopause  may  be  expected  to  give  rise  to 
neuropathic  affections  and  to  cardiac  disturbances  in  a  similar 
manner. 

The  woman's  state  of  general  health  is  likewise  of  importance 
in  determining  whether  the  course  of  the  menopause  will  be  favour- 
able or  unfavourable.  Perfectly  healthy  women,  with  a  quiescent 
temperament,  and  in  favourable  circumstances  of  life,  will  pass  most 
easily  through  the  climacteric  period  without  disturbance  of  their 
general  condition.  Every  departure  from  normal  health  has  an  un- 
favourable influence  upon  the  course  of  the  climacteric.  In  women 
of  a  plethoric  habit  of  body,  there  is  an  especial  tendency  at  this 
time  to  the  occurrence  of  symptoms  of  stasis  and  hyperaemia. 
Chlorotic  and  anaemic  women  are  more  prone  than  others  to  suffer 
at  the  time  of  the  menopause  from  uterine  haemorrhages.  Women 
of  a  sanguino-erethistic  constitutional  disposition  often  manifest  at 
this  epoch  a  tendency  to  neuroses  and  psychoses.  Those  women 
have  the  best  prospect  of  a  smooth  and  undisturbed  passage  through 
the  climacteric  age,  who  enter  upon  it  in  a  state  of  perfect  health. 
Less  favourable  is  the  prognosis  in  the  case  of  those  women  who 
already  some  time  before  the  climax,  at  the  outset  of  the  fourth 
decade  of  their  lives,  have  begun  to  complain  of  severe  haemorrhages 
and  various  other  pathological  states. 

Regarding  the  influence  which  the  sexual  activity  of  a  woman 
during  the  menacme  exercises  upon  the  course  of  the  climacteric, 
it  may  be  said,  generally  speaking,  that  a  previous  free  exercise 
of  the  sexual  functions  in  normal  conditions  has  a  favourable  influ- 
ence upon  the  state  of  health  during  the  menopause.  Women  who 
have  been  married  for  many  years,  who  have  had  many  children, 
and  who  have  suckled  these  children,  pass  through  the  changes  of 
the  climacteric  much  more  easily  than  old  maids,  than  women  who 
have  lived  for  many  years  in  continent  widowhood,  or  than  women 
who  have  had  very  few  children  or  none  at  all.  The  practice  of 
prohibitive  coitus,  i.  e.,  the  use  during  intercourse  of  methods  of 
preventing  the  occurrence  of  conception,  a  form  of  sexual  immo- 
rality which  has  become  extraordinarily  common  during  the  last 
few  decades,  has  an  unfavourable  influence  upon  the  course  of  the 
climacteric.  Unfavourable,  also,  is  the  effect  of  great  sexual  activity 
during  the  four  or  five  years  immediately  preceding  the  menopause. 
Women  who  marry  shortly  before  the  commencement  of  the  climac- 
teric, and  those  who  have  given  birth  to  a  child  shortly  before  this 
time,  commonly  experience  very  severe  disturbances  during  the 
menopause.  Prostitutes  who  continue  the  active  pursuit  of  their 
profession  until  the  climacteric  age,  have  at  this  time  much  to 
suffer.  Women  who  have  had  difficult  deliveries,  or  several  mis- 
carriages, or  severe  puerperal  illnesses  —  and  indeed,  speaking  gen- 


580  THE  SEXUAL  LIFE  OF  WOMAN. 

erally,  those  women  who  have  been  subject  to  any  kind  of  disease 
of  the  reproductive  organs — are  apt  to  suffer  from  serious  disturb- 
ances of  the  general  health  during  the  climacteric  period. 

The  mode  in  which  the  cessation  of  menstruation  takes  place,  is 
also  causally  connected  with  the  easy  or  difficult  course  of  the  meno- 
pause. Premature  cessation  of  menstruation,  or  very  sudden  inter- 
ruption of  this  function,  has  a  deleterious  effect,  manifesting  itself 
both  by  local  disorders  of  the  reproductive  organs,  and  by  general 
disturbances  in  the  nervous  system  and  in  the  circulatory  organs. 
On  the  other  hand,  a  late  menopause  and  a  gradual  cessation  of 
menstruation,  are  both  usually  accompanied  by  a  favourable  course 
of  the  climacteric  phenomena. 

The  influence  of  sexual  activity  upon  the  course  of  the  climac- 
teric is  described  by  Busch  in  the  following  terms :  "  Women  who 
have  led  an  exhausting  mode  of  life,  who  have  had  intercourse  too 
frequently,  those  who  have  been  given  to  onanism  or  to  some  other 
sexual  irregularity,  and  who  therefore  enter  upon  the  menopause 
with  flaccid  and  deteriorated  reproductive  organs,  are  liable  to 
haemorrhagic  and  mucuous  fluxes,  to  prolapse,  carcinoma,  dropsies, 
enlargements,  and  suppurative  processes.  Women,  on  the  other 
hand,  who  have  lived  a  life  of  strict  isolation,  and  who  have  forcibly 
repressed  all  sexual  inclinations,  frequently  suffer  from  ossifications, 
indurations,  and  atrophic  conditions  of  the  reproductive  organs,  and 
also  from  neoplasmata." 

After  an  artificial  menopause,  induced  by  the  operative  removal 
of  the  ovaries,  similar  manifestations  occur  to  those  witnessed  dur- 
ing the  natural  menopause.  Similar  disturbances  and  troubles  occur 
in  both  cases,  but  in  the  artificial  menopause  they  are  commonly 
more  severe  than  in  the  natural;  they  last  also  for  a  longer  time, 
varying  usually  from  three  to  six  years ;  moreover,  in  the  artificial 
menopause,  as  in  the  natural,  the  disturbance  of  health  is  more 
severe  and  lasts  longer  in  proportion  to  the  youth  of  the  individual. 
Further,  in  the  artificial  menopause  also,  the  intensity  and  the  dura- 
tion of  the  climacteric  manifestations  are  influenced  by  the  con- 
stitutional state  and  by  the  condition  of  the  genital  organs  at  the 
time  when  the  operation  is  performed.  We  note,  moreover,  that, 
just  as  in  the  physiological  menopause,  the  attendant  troubles  are 
most  violent  in  the  initial  period,  and  then  gradually  subside,  so 
also  after  the  induction  of  an  artificial  menopause  by  the  removal  of 
the  ovaries,  the  resultant  disturbances  rapidly  increase  in  severity, 
to  attain  their  maximum  in  from  three  to  six  months,  and  then,  after 
lasting  for  a  year  or  so,  they  gradually  become  less  severe,  until  they 
are  ultimately  extinguished. 

The  extensive  process  of  transformation  which  goes  on  in  a 
woman's  system  during  this  period  of  the  sexual  life,  from  the  very 


SEXUAL  EPOCH  OF  THE  MENOPAUSE.  581 

first  diminution  in  ovarian  activity  to  the  complete  extinction  of  the 
reproductive  functions,  manifests  itself  throughout  the  organism  by 
means  of  a  series  of  changes  which  can  for  the  most  part  be  referred 
either  to  states  of  blood-stasis  and  their  consequences  —  congestion 
of  various  organs,  haemorrhages,  and  disorders  of  secretion  —  or 
else  to  perversions  of  nervous  function. 

The  most  manifold  symptoms  of  disordered  circulation  may  oc- 
cur: hyperaemic  states  of  the  central  nervous  system,  flushings  of 
the  face,  the  so-called  fugitive  heats  (Ger.  fliegende  Hitze},  a  ten- 
dency to  epistaxis,  to  haemorrhoidal  flux,  and  to  profuse  perspira- 
tion. The  changes  which  take  place  in  the  reproductive  organs  at 
the  time  of  the  menopause  give  rise  to  venous  engorgement  and  to 
collateral  congestions.  Such  a  condition  of  venous  hyperaemia  may 
occur  in  the  gastric  and  the  intestinal  mucous  membrane,  giving 
rise  to  various  dyspeptic  manifestations,  and  at  times,  when  severe, 
even  to  actual  gastric  and  intestinal  catarrh.  Hyperaemia  of  the 
liver  may  also  arise.  In  this  case,  the  pressure  of  the  distended 
blood-vessels  on  the  biliary  ducts  may  interfere  with  the  outflow  of 
the  bile,  and  thus  give  rise  to  a  slight  icterus.  Further,  the  intra- 
abdominal  venous  congestion  leads  to  overfilling  of  the  haemor- 
rhoidal veins,  and  hence  to  bleeding  piles. 

When  the  congestion  is  long-lasting,  various  further  morbid 
changes  may  arise,  pulmonary  hyperaemia  may  eventuate  in  bron- 
chitis, hyperaemia  of  the  cerebral  meninges  may  cause  very  severe 
headache,  there  may  be  syncopal  attacks,  tinnitus  aurium,  choroidal 
congestion,  impaired  vision,  etc. 

Congestion  of  a  more  active  nature  arises  from  an  increased  and 
usually  accelerated  flow  of  blood  through  the  vessels  of  a  part  in 
which  the  resistance  to  the  blood  stream  has  been  lowered  propor- 
tionately to  its  propulsive  force.  In  this  way  arises  that  character- 
istic symptom  of  the  menopause  known  as  ardor  fugax  —  fugitive 
heat  —  one  link  in  the  long  chain  of  vasomotor  manifestations 
occurring  at  this  period  of  life.  Fugitive  heats  are  commonly  most 
clearly  marked  in  the  face,  head,  and  neck,  in  which  region  there 
suddenly  occurs  a  reddening  of  the  skin,  with  diffuse  and  increasing 
subjective  sensation  of  heat.  At  the  same  time  there  is  often  a  sense 
of  tension,  as  if  the  part  were  .about  to  burst  Actual  slight  swell- 
ing may  be  noticed,  the  eyes  sparkle  and  are  somewhat  prominent, 
the  head  feels  heavy,  stupid,  and  dizzy.  Sometimes  these  symptoms 
last  for  a  considerable  time;  at  other  times  they  .terminate  speedily 
and  suddenly  with  a  local  perspiration  or  with  an  attack  of  epistaxis. 
Not  infrequently,  after  lasting  a  short  time  in  one  region,  they  pass 
away  as  rapidly  as  they  came,  but  are  immediately  succeeded  by  a 
similar  attack  in  some  other  part  of  the  body,  or  by  vasomotor 


582  THE  SEXUAL  LIFE  OF  WOMAN. 

phenomena  of  a  slightly  different  kind.  Thus,  such  a  flushing-  and 
heat  of  the  face  may  be  replaced  by  a  sudden  sense  of  heat  in  the 
small  of  the  back  or  in  the  sacral  region,  by  pruritus  of  the  extrem- 
ities, by  palpitation  of  heart,  or  by  an  attack  of  pseud-angina. 

A  further  consequence  of  active  hyperaemia  is  the  onset  of  those 
confused  states,  so  common  in  the  climacteric  age,  of  mental  and 
bodily  disquiet,  which  find  expression,  now  in  states  of  excitement, 
and  now  in  states  of  depression.  So  we  often  observe  change  of 
disposition,  associated  with  incapacity  for  regular  work,  whilst  sleep 
is  restless,  and  much  disturbed  by  dreams ;  and  again  states  of  dizzi- 
ness, a  sense  of  mental  uneasiness  and  confusion,  and  even  actual 
delirium. 

In  the  skin,  in  addition  to  the  fugitive  heats,  we  often  have  a 
peculiar  pricking,  itching,  or  stabbing  sensation,  and  various  kinds 
of  hyperaesthesia,  frequently  associated  with  disturbances  of  tactile 
sensation.  We  observe  also  muscular  twitchings,  and  general  weak- 
ness of  the  organs  of  locomotion. 

In  association  with  the  passive  and  active  hyperaemias  of  the 
menopause,  we  frequently  see  increase  or  some  qualitative  change 
in  the  various  secretions.  Above  all,  these  changes  affect  the 
Various  secretions  of  the  different  reproductive  organs,  but  we  have 
also  increased  intestinal  secretion,  leading  to  diarrhoea,  increased 
excretion  of  urinary  deposits,  and  increased  secretion  by  the  skin. 
Symptoms  which  are  common  at  the  menarche,  and  frequently  re- 
curs at  the  menopause,  are :  headache,  migraine,  a  state  of  pseudo- 
narcotism,  slight  hysterical  attacks,  indications  of  moral  insanity, 
lumbo-abdominal  neuralgias,  neuralgia  of  the  breasts,  leucorrhoea, 
and  various  skin  eruptions. 

According  to  Tilt,  the  changes  occurring  in  the  organism  at  the 
climacteric  period  may  be  summarized  under  the  following  heads : 

1.  Increased  elimination  of  carbonic  acid  by  the  lungs, 

2.  Increased  elimination  of  uric  acid  in  the  urine, 

3.  Increased  perspiration, 

4.  Increased  mucous  flux, 

5.  Haemorrhages  from  various  organs. 

As  regards  the  first  point,  the  extensive  researches  of  Andral  and 
Gavaret  have  shown  that  in  the  female  sex  the  quantity  of  carbonic 
acid  eliminated  by  the  lungs  diminishes  when  menstruation  first 
appears  at  puberty,  but  increases  again  at  the  climacteric  age,  when 
menstruation  ceases  —  whereas  in  the  male  a  gradual  diminution 
in  the  elimination  of  carbonic  acid  begins  already  in  the  36th  year  of 
life;  in  old  age  the  quantity  eliminated  is  greatly  reduced  in  both 
sexes  alike. 


SEXUAL  EPOCH  OF  THE  MENOPAUSE.  583 

CHANGES  IN  THE  FEMALE  REPRODUCTIVE  ORGANS  AT  THE 
MENOPAUSE. 

In  considering  the  changes  that  take  place  in  the  female  repro- 
ductive organs  at  this  period  of  life,  we  must  distinguish  between 


Fibrous  layer  of  the  corti- 
cal substance. 


Cellular  layer  with  follicles, 


Blood  vessel. 
FIG.  84. —  Sagittal  section  through  the  ovary  of  a  girl  aged  16. 

the  proper  period  of  the  climacteric,  with  its  various  manifestations 
antecedent  to  and  associated  with  the  irregularity  and  ultimate  ces- 
sation of  menstruation,  from  the  condition  of  old  age  in  which 
menstruation  has  actually  and  completely  ceased,  in  which  the  men- 
opause has  been  fully  accomplished,  and  in  which  the  changes  of 
senescence  have  set  in  at  once  in  the  organs  of  the  reproductive 
system  and  in  the  organism  as  a  whole. 

The  most  important  and  most  significant  changes  of  this  sexual 
epoch  are  unquestionably  the  anatomical  alterations  in  the  ovaries. 
A  good  many  years  ago  I  undertook  an  investigation  whose  purpose 
was  to  follow  the  natural  involution  of  the  graafian  follicles  from 
the  time  of  the  climax  on  into  old  age,  and  for  this  purpose  I  ex- 
amined a  very  large  number  of  ovaries  of  women  at  ages  varying 
from  42  to  75  years  (Archiv.  fur  Gynecologic,  Bd,  XII.,  Heft  3). 

Throughout  these  years  a  slow  but  continuously  progressive 
atrophy  proceeds  in  the  ovaries ;  they  become  smaller  and  denser, 
diminishing  especially  in  height  and  width ;  their  surface  becomes 
extremely  uneven ;  and  in  extreme  old  age  they  wither  away  until 
no  more  is  left  in  the  region  formerly  occupied  by  the  ovaries  than 
a  flattened  fibro- vascular  thickening  (Figs.  84-88).  The  histolog- 
ical  characteristic  of  the  changes  in  the  ovary  which  proceed 


584  THE  SEXUAL  LIFE  OF  WOMAN. 

gradually  from  the  commencement  of  the  menopause  to  extreme  old 
age,  may  be  summed  up  as  consisting  in  a  continual  increase  and 
new  formation  of  the  connective  tissue  stroma  at  the  expense  of  the 


Strata   of    dense  connective  tissue 
fibres. 


Granule  spheres. 
Granule  spheres. 

Tortuous  and   dilated   bloodvessel. 

FIG.  85. —  Sagittal  section  through  the  ovary  of  a  woman  aged  72  years. 

cellular  layer,  accompanied  by  retrogressive  metamorphosis  of  the 
graafian  follicles.  % 

The  connective  tissue  ground  substance  of  the  ovary  increases 
from  the  periphery  towards  the  centre,  and  progressively  compresses 
the  epithelial  structures  of  the  organ.  In  the  outermost  layer  of 
the  ovarian  stroma,  the  so-called  tunica  albuginea,  the  strata  of 
short,  dense  connective  tissue  fibres  increase  notably  in  number,  so 
that  whereas  at  first  three  layers  at  most  could  be  distinguished,  the 
tunic  ultimately  comes  to  consist  of  from  six  to  eight  layers ;  at  the 
same  time  also  the  interior  ovarian  stroma  becomes  exceedingly 
dense,  so  that  numerous  well-defined  interlacing  bundles  of  fibres 
can  be  made  out  in  its  substance. 

The  first  retrogressive  metamorphosis  which  can  be  observed  in 
the  graafian  follicles  is  fatty  degeneration,  the  formation  of  granule 
spheres.  Whilst  the  membrana  propria  (the  theca  folliculi)  of  the 
follicle  remains  quite  unaltered,  we  observe  in  the  membrana  granu- 
losa,  in  addition  to  the  ovum,  and  the  ordinary  cells  of  this  layer, 
spherical  aggregates  of  fat  droplets,  the  granule  spheres,  which  con- 
tinually increase  in  size,  until  ultimately  of  the  cellular  contents  of 
the  follicle  nothing  whatever  remains,  and  it  now  appears  full  of 
granule  spheres  and  fluid.  The  theca  folliculi  has  now  lost  its 
spherical  shape,  and  assumes  an  ovid  form  (Fig.  89). 

In  a  later  stage  of  the  degeneration  of  the  graafian  follicle,  it 
appears  as  a  vesicular  body  with  a  relaxed  wall,  thrown  into 
numerous  folds,  this  folded  wall  being  formed  by  the  theca  folliculi. 


SEXUAL  EPOCH  OF  THE  MENOPAUSE. 


585 


The  cavity  of  the  follicle  is  reduced  to  a  mere  cleft,  filled  with  a 
transparent  substance,  and  the  space  between  this  cleft  and  the 
inner  surface  of  the  theca  folliculi  is  occupied  by  round  cells  and  a 


5-Membrana  granulosa. 


Ovum  -  ~*%^!SX§BBaWBBBESrH^ifi Discus  proligerus 


Vitellus.  --  G        li 

FIG.   86. —  Diagrammatic    representation   of   the    Graafian    Follicle. 


fibrous  intercellular  substance,  and  is  traversed  by  a  vascular  net- 
work.    This  second  stage  of  the  retrogression  of  the  follicle  may 


FIG.  87. — Ovary  of  a  girl  aged  19 
years.     (Normal  size.) 


FIG.  88. —  Ovary  of  a  woman  72  years 
of  age.      (Normal    size.) 


therefore  be  designated  the  stage  of  vesicular  degeneration 
(Fig.  90). 

In  the  last  stage  of  this  retrogressive  metamorphosis,  we  find  the 
follicle  completely  transformed  to  a  fibrous  mass.  It  appears  as  an 
elongated  oval  body,  much  lobulated,  connected  with  the  surround- 
ing stroma  by  thick  strands  of  fibres ;  a  trace  of  the  original  cavity 
can  still  be  distinguished  in  the  form  of  a  narrow  cleft,  without 
distinguishable  contents.  The  tissue  of  this  body  consists  of  con- 
nective tissue  fibres,  with  interspersed  nuclei  and  nuclear  fibres 
(Fig.  91). 

The  three  stages  I  have  observed  in  the  retrogression  of  the 
follicle,  of  which  I  have  given  a  summary  account  above,  may,  I 
think,  be  explained  in  the  following  manner :  When  the  woman's 
reproductive  activity  ceases,  the  graafian  follicles  become  subject  to 
a  retrogressive  metamorphosis,  a  fatty  degeneration  setting  in  in  the 
cells  of  the  membrana  granulosa  and  in  the  ovum,  until  ultimately 


586 


THE  SEXUAL  LIFE  OF  WOMAN. 


the  whole  of  the  granular  epithelium  has  undergone  atrophy.  The 
follicle  now  undergoes  a  vesicular  transformation  with  shrinkage 
of  its  cavity,  and  with  the  formation  of  a  new  tissue  which  appears 
to  be  young  connective  tissue.  As  time  goes  on,  this  new  connective 
tissue  is  formed  in  increasing  quantities,  until  finally  the  entire 
follicle  is  transformed  into  a  firm  fibrous  mass. 

Thus  we  are  led  to  infer  that  the  gradual  but  extensive  thickening 
of  the  tunica  albuginea  (i.  e.,  the  outer,  condensed  layer  of  the 
ovarian  stroma),  which,  as  we  have  seen,  always  occurs  at  the 
climacteric  period,  offers  a  hindrance  to  the  bursting  of  the  follicles 


FIG.  89. 

as  they  mature,  and  in  this  we  find  the  explanation  of  the  irregu- 
larity of  menstruation  and  of  the  various  troubles  which  attend  the 
performance  of  that  function  at  the  time  of  the  menopause.  It  is 
reasonable  to  assume  that  the"  resistance  of  this  thickened  tunica 
albuginea  is  responsible  for  the  fact  that  the  interval  between  the 
bursting  of  the  successive  follicles  is  now  greater  than  normal,  as 
much  as  six  or  eight  weeks  —  this  retardation  of  menstruation  being 
one  of  the  commonest  ways  in  which  the  onset  of  the  menopause  is 
first  manifested.  Another  phenomenon  connected  with  the  onset  of 
the  menopause  also  finds  a  plausible  explanation  in  the  anatomical 
grounds  just  mentioned.  As  already  pointed  out,  in  parous  women 
the  menopause  sets  in  later  than  in  nulliparae.  At  every  pregnancy, 
the  ovaries  share  in  the  more  abundant  nutrition  of  all  the  repro- 
ductive organs,  due  to  the  general  dilatation  of  the  intra-pelvic 
vessels  which  accompanies  this  process ;  hence  the  ovaries  become 
larger,  richer  in  lymph,  and  therefore  softer,  the  cellular  elements 
increase  in  size,  and  perhaps  also  in  number,  and  it  is  readily  con- 


SEXUAL  EPOCH  OF  THE  MENOPAUSE.  587 

ceivable  that  in  such  ovaries  the  cellular  elements  are  able  for  a 
longer  time  to  resist  the  induration  and  the  new  formation  of  con- 
nective tissue  which  occur  at  the  climacteric. 

The   numerous   nervous   disturbances   of  the   climacteric   epoch 
would  appear  also  to  depend  upon  the  hyperplasia  of  the  ovarian 


FIG.  90. 

stroma  which  we  have  observed  to  be  the  characteristic  anatomical 
change  in  the  ovaries  at  this  period  of  life. 

Associated  with  the  fibrous  transformation  of  the  graafian 
follicles  there  is,  however,  a  failure  of  the  so-called  internal  secretion 
of  the  ovaries,  a  matter  to  which  much  attention  has  recently  been 
paid.  Broti'n-Scquard  has  especially  maintained  that  the  ovaries 
secrete  a  substance  which  enters  the  blood,  a  substance  which,  not- 
withstanding the  fact  that  its  presence  cannot  be  proved  either  by 
chemical  or  any  other  means  known  to  us,  yet  is  of  considerable 
importance  for  the  maintenance  of  the  equilibrium  of  mental  and 
physical  well-being.  It  is  supposed  that  the  various  profound  dis- 
turbances of  the  general  system  occurring  at  the  menopause1  are 
dependent  upon  the  cessation  of  this  internal  secretion  of  the  ovary 
—  disturbances  which  rise  to  a  maximum  as  the  atrophy  of  the 
ovary  proceeds,  and  which  only  gradually  pass  away  after  a  con- 
siderable lapse  of  time. 

After  the  menopause  is  completely  over,  in  the  ovaries,  as  in 
other  parts  of  the  female  reproductive  organs,  the  signs  of  senile 
degeneration  make  their  appearance. 

'NOTE. —  In  Germany,  the  term  Ausfallserscheinungen  is  used  as  a  general 
name  for  the  various  disorders  of  the  climacteric  period.  The  word  A  us  fall 
means  literally  a  falling  out,  or  shedding,  as  of  the  hair.  No  precise  English 
equivalent  of  the  term  is  known  to  me,  nor  is  one  really  needed,  the  phrase 
disorders  of  the  climacteric  being  sufficiently  distinctive. —  TRANSL. 


588 


THE  SEXUAL  LIFE  OF  WOMAN. 


In  old  women,  we  find  the  ovaries  either  shrunken  to  the  form  of 
small  fibrous  cords,  or  else  degenerated  to  form  cysts  of  smaller  or 


FIG.  91. 


larger  size,  the  stroma  surrounding  these  cysts  being  extremely 
hard,  dense,  and  tough. 


FIG   92. —  Sagittal  section  through  the  Cervix  of  a  woman  26  years  of  age. 
Dendriform  branched  Glands. 


Whereas  at  the  commencement  of  the  climacteric  period,  the 
uterus  commonly  exhibits  a  slight  increase  in  size,  owing  to  the 
condition  of  passive  hyperaemia  already  described,  subsequently  a 
gradual  diminution  in  the  size  of  the  organ  may  be  observed.  This 
atrophy  begins  with  the  portio  vaginalis  and  proceeds  upwards. 


SEXUAL  EPOCH  OF  THE  MENOPAUSE. 


Whilst  the  body  still  appears  undiminished  in  size,  the  vaginal  por- 
tion will  be  found  already  shorter,  more  slender,  and  more  flaccid. 
Gradually,  however,  the  entire  organ  is  involved  in  the  atrophic 
process.  The  uterus  is  then  smaller  than  formerly,  its  walls  are 
thinner,  its  cavity  reduced  in  size.  Its  vascularity  and  its  sensi- 


FIG.  93. —  Sagittal  section  through  the  Cervix  of  a  woman  65  years  of  age. 
Glands  which  have  undergone  Cystic  Degeneration. 

bility  are  alike  diminished.  The  external  os  is  smaller,  and  the 
internal  os  is  sometimes  entirely  obliterated.  There  is  a  tendency 
at  the  climacteric  period  for  the  tubulo-racemose  glands  of  the 
cervical  mucous  membrane  (Fig.  92)  to  undergo  a  cystic  degenera- 
tion (Fig.  93),  and  hence  arise  the  cysts  which  are  so  commonly 


FIG.  94. —  Cervix  of  a  woman  70  years  of  age.     The  Cervical  glands  have 
undergone  Cystic  Degeneration. 

met  with  on  the  portio  vaginalis  of  women  at  this  time  of  life, 

cysts  varying  in  size  from  that  of  a  millet  seed  to  that  of  a  pea. 


590 


THE  SEXUAL  LIFE  OF  WOMAN. 


In  advanced  life,  the  formation  of  such  cysts  may  be  regarded  as 
normal,  and  sometimes  in  the  form  of  grape-like  clusters  they  almost 
completely  occupy  the  lumen  of  the  cervical  canal.  (Figs.  94,  95, 
96,  and  97). 

Not  infrequently,  these  cysts  lead  to  the  formation  of  polypi,  by 
enlarging  until  the  mucous  membrane  projects  so  far  that  a  stalk 
is  formed. 

Examining  the  bodies  of  47  women  who  died  at  ages  varying 
from  42 "to  80  years,  I  found  in  28  ovula  Nabothi  in  the  cervical 
mucous  membrane,  for  the  most  part  at  the  os  uteri  externum,  but 
in  some  cases  also  extending  up  to  the  os  internum,  sometimes 
between  the  plicae  palmatae,  sometimes  isolated,  sometimes  grouped. 

Sometimes  in  old  women  no  trace  of  a  vaginal  portion  remains, 
and  the  uterus  is  found  to  be  transformed  to  a  small,  thin-walled, 
shrunken  body,  no  more  than  one  fourth  of  its  original  size ;  in 
such  cases  the  saying  of  Graaf  appears  to  be  justified,  that  after 
the  menopause  the  uterus  returns  to  the  size  it  has  in  the  young  girl. 
In  the  majority  of  such  cases,  the  cavity  of  the  uterus  is  also  con- 
tracted (concentric  atrophy).  It  sometimes  happens,  however,  that 


FIG.   95. —  Ovula   Nabothi   in   the   Portio   Vaginalis. 

in  old  age  the  os  externum  and  the  os  internum  are  the  seat  of 
atresia,  whilst  the  intermediate  portion  of  the  cervical  canal  remains 
unaffected.  In  this  way,  especially  when  the  cervical  canal  and  the 
cavity  of  the  body  of  the  uterus  are  distended  with  mucus  or  with 
fungous  growths,  is  produced  what  is  known  as  the  uterus  bicamero- 
tus  vetularum. 

In  many  cases,  when  the  cervical  canal  has  been  obliterated,  we 
find  the  uterine  cavity  distended  with  mucous  secretion  (excentnc 


SEXUAL  EPOCH  OF  THE  MENOPAUSE.  591 

atrophy).  The  substance  of  the  uterine  wall  is  in  old  age  commonly 
dense  and  tough,  but  occasionally,  in  extreme  old  age,  less  firm 
than  formerly,  withered  and  friable,  and  traversed  by  degenerated 
arteries,  and  in  this  state  it  is  predisposed  to  haemorrhages  (apo- 
plexia  uteri).  Such  intra-mural  haemorrhages  usually  occur  in  the 
fundus ;  the  friable  uterine  substance  has  then  a  blackish-red  appear- 
ance, infarcted  with  extravasated  blood ;  sometimes  the  uterine 
cavity  is  also  filled  with  blood.  In  general  it  may  be  said  that 
when  the  menopause  is  completely  over,  when  uterine  activity  has 
entirely  ceased,  the  uterus  returns  to  the  state  in  which  it  was 
before  the  menarche — it  is  physiologically  dead. 

The  tubes  become  flaccid,  thinner,  shorter,  and  are  at  times  oblit- 
erated. In  the  mucous  membrane  of  the  tubes  in  old  women  we  no 
longer  find  any  trace  of  the  glands  described  by  Hennig;  the  epi- 
thelial cells  have  also  lost  their  cilia. 

During  the  climacteric  period,  the  vagina  is  usually  relaxed  and 
roomy,  the  mucous  membrane  is  smooth,  injected  and  secretes 
freely;  subsequently,  in  old  age,  it  becomes  firm,  tough  and  dry. 


FIG.  96. —  Vesicle    (Ovula   Nabothi)    from 


Uterine   Mucous   Membrane. 


Wcndclcr  found  that  the  initial  change  of  the  climacteric  in  the 
ovary  is  a  chronic  and  progressive  endarteritis  obliteTans;  the 
result  of  this  process  is,  in  addition  to  the  obliteration  of  the  follicles, 
a  continually  increasing  hyaline  degeneration  of  the  smallest  arteries 
and  the  arterioles,  especially  along  the  line  of  transition  between 
the  cortical  and  the  medullary  substance  of  the  organ ;  this  degenera- 
tion extends  to  the  surrounding  connective  tissue,  and  thus  leads  to 


592  THE  SEXUAL  LIFE  OF  WOMAN. 

the  formation  of  peculiar,  vitreous,  translucent  foci  of  sclerotic  con- 
nective tissue,  containing  few  cells  or  none ;  these  are  the  so-called 
corpora  fibrosa  or  corpora  albicantia.  Only  subsequently  to  the  for- 
mation of  these  bodies  does  the  characteristic  wrinkling  of  the  sur- 
face of  the  ovary  occur,  with  general  shrinkage  of  the  organ,  these 


- 


FIG.  97. —  Mucous   glands   undergoing   Cystic   Degeneration. 

changes  being  due  to  the  contraction  that  sets  in  in  the  numerous 
scattered  foci  of  connective  tissue,  which,  as  already  mentioned,  are 
situated  in  close  proximity  to  the  cortex. 

The  gradual  atrophy  of  the  uterus  after  the  extinction  of  its 
sexual  activity  leads  to  a  diminution  in  all  the  diameters  of  the 
organ,  so  that  in  old  women  it  becomes  flattened  as  in  childhood,  all 
its  curves  having  disappeared;  the  muscular  substance  is  replaced 


SEXUAL  EPOCH  OF  THE  MENOPAUSE.  593 

by  connective  tissue;  and  the  portio  vaginalis  dwindles  and  even 
entirely  disappears. 

As  regards  the  bacterial  flora  of  the  genital  organs  of  elderly 
women,  Menge  and  Koenig  find  that  the  vagina  for  the  most  part 
contains  bacteria  which  do  not  thrive  when  cultivated  aerobically  on 
alkaline  agar  plates.  In  exceptional  cases,  however,  such  bacteria 
are  found,  and  may  even  be  sufficiently  vigorous  to  produce  pyogenic 
infection.  According  to  Strogamoff,  the  vagina  in  all  circumstances 
contains  a  great  variety  of  micro-organisms  —  cocci,  diplococci  and 
rod-forms.  Rod-forms  are  the  prevailing  types  found  in  normal 
conditions  in  elderly  women,  but  they  are  much  smaller  than  in 
women  who  are  still  in  the  period  of  reproductive  activity.  Organ- 
isms liquefying  gelatine  were  found  in  one  instance  only,  a  case  of 
vaginal  prolapse.  In  one  half  of  the  cases  examined,  there  was  no 
development  of  culture  media  inoculated  from  the  cervix  uteri, 
whether  on  agar  or  gelatine. 


THE  TIME  OF  THE  MENOPAUSE. 

The  age  at  which  the  menopause  begins  is  one  which  varies  owing 
to  manifold  conditions,  congenital  and  acquired,  owing  to  the  local 
influences  which  have  been  brought  to  bear  on  the  reproductive 
organs  during  the  menacme,  and  to  the  general  circumstances  of 
life  during  this  period.  In  Northern  Europe  it  commonly  begins 
some  time  between  the  ages  of  40  and  50  years.  According  to  the 
most  trustworthy  statistical  data,  the  commonest  age  for  the  onset 
of  the  menopause  is  between  the  ages  of  45  and  50  years.  Next  to 
these  in  frequency  we  find  the  menopause  commencing  between  the 
ages  of  40  and  45  years.  If,  however,  the  menopause  does  not 
begin  during  the  fifth  decennium,  it  is  more  apt  to  occur  during 
the  quinquennium  after  50  than  during  the  quinquennium  preceding 
40  years  of  age ;  that  is  to  say,  an  abnormally  late  menopause  is 
more  often  met  with  than  an  abnormally  early  menopause.  In  a 
very  small  proportion  of  women  does  the  menopause  begin  either 
after  the  age  of  55  or  before  the  age  of  35. 


THE  AGE  AT  WHICH  THE  MENOPAUSE  OCCURS. 

My  own  observations  show  that  the  age  at  which  the  menopause 
begins  is  affected  by  the  following  circumstances: 

1.  The  race  (nationality)  of  the  woman. 

2.  The  age  at  which  the  menarche  occurred. 

3.  The  sexual  activity  of  the  woman  during  the  period  of  the 

38 

[099] 


594  THE  SEXUAL  LIFE  OF  WOMAN. 

menacme,  the  number  of  her  pregnancies,  the  exercise  or  neglect  of 
the  function  of  lactation. 

4.  The  social  circumstances  of  the  woman's  life. 

5.  General  constitutional  and  pathological  conditions. 

i.     Race. 

From  the  statistical  data  regarding  the  age  at  which  the  meno- 
pause occurs  among  the  women  of  the  various  nations  of  Northern 
Europe,  it  appears  that  the  latest  average  age  for  the  cessation  of 
menstruation  is  met  with  in  Lapland,  namely  49.4  years ;  next  comes 
Norway,  where  the  average  age  is  48.9 ;  next  Germany,  where  the 
average  age  is  47;  next  England,  46.1 J,  next  Russia,  44;  and 
finally  Austria,  42.2.  In  the  four  principal  capital  cities,  the  average 
age  is :  in  London,  45.5 ;  in  Paris,  43.65 ;  in  Vienna,  43,  and  in 
Berlin,  47.  Generally  speaking,  in  southern  countries  the  cessation 
of  menstruation  occurs  at  an  earlier  age  than  in  northern  countries, 
as  the  following  comparison  shows :  northern  countries  :  England 
(Tilt),  48  to  50;  France  (Courty),  50;  North  Germany  (Mayer), 
50;  Austria  (Szukits),  42;  southern  counties:  Persia  (Chardin), 
27 ;  Java,  30 ;  various  Asiatic  races,  30  to  40. 

In  the  case  of  500  women  of  various  nationalities  in  whom  I 
was  able  to  ascertain  by  personal  observation  the  age  at  which 
menstruation  ceased,  I  found  that  the  menopause  occurred : 

In  the  quinquennium : 35  to  40  in    48  women 

In  the  quinquennium 40  to  45  in  141  women 

In  the  quinquennium 45  to  50  in  177  women 

In  the  quinquennium 50  to  55  in    89  women 

455 

Thus  we  see  that  in  about  one  tenth  of  my  cases,  menstruation 
ceased  between  the  ages  of  35  and  40;  in  more  than  one-fourth, 
between  the  ages  of  40  and  45 ;  in  more  than  one-third  between  the 
ages  of  45  and  50;  and  in  about  one-sixth  between  the  ages  of  50 
and  55.  In  267,  that  is,  in  more  than  one-half  of  the  500,  menstru- 
ation ceased  between  the  ages  of  42  and  51.  In  28  women,  menstru- 
ation ceased  before  the  age  of  35 ;  and  in  17,  after  the  age  of  55. 
In  a  very  large  majority  of  my  500  cases  the  women  were  of 
German  or  Austro-Hungarian  nationality ;  next,  in  order  of  fre- 
quency, came  Poles,  Russians,  women  of  various  southern  countries, 
Swedish  women.  In  women  of  Sclavonic  nationality,  menstruation 
ceased  remarkably  late  as  compared  with  women  of  German 
nationality. 

Bncrre  de  Boismont,  Tilt,  Courty,  and  various  other  observers, 
have  published  statistical  data  regarding  the  age  at  which  menstru- 
ation ceases  in  women  of  different  nationalities.  Krieger,  compiling 


SEXUAL  EPOCH  OF  THE  MENOPAUSE. 


595 


from  several  authors,  statistics  relating  to  2291  women  (European) 
gives  the  following  average  results:  menstruation  ceased 

Between  the  ages  of  35  and  40  in 272  women  n  .87  per  cent 

Between  the  ages  of  40  and  45  in 595  women  25.97  per  cent. 

Between  the  ages  of  45  and  50  in 940  women  41 .03  per  cent. 

Between  the  ages  of  50  and  55  in 334  women  14.58  per  cent. 

Before  35  and  after  55  in 150  women  6.54  per  cent. 


2291 


99-99 


We  append  a 'statistical  table  showing  the  average  age  at  which 
menstruation  ceases  in  women  of  different  European  nationalities: 


Ger- 
many. 

Austria- 
Hun- 
gary. 

France 
(Paris). 

England 
(Lon- 
don). 

Russia. 

Den- 
mark. 

Nor- 
way. 

Lap- 
land. 

Number       of 

cases  

824 

256 

178 

500 

IOO 

312 

391 

34 

Average    age 

at  the  ces- 

sation      of 

menstrua  - 

tion  

47  •  o 

42.2 

44  •  o 

46   z 

A  e     n 

AA    8 

Aft    a 

An     A 

Observer.  .  .  . 

Magar 

Szukits 

Brierre 

Tilt 

45  -y 
Lieven 

44.0 

Hanno- 

40 .  y 

Faye 

4y  •  •» 
Vogt 

de 

ver 

and 

Bois- 

Vogt 

mont 

2.     The  Age  at  Which  the  Menarche  Occurred. 

Until  recently,  it  was  generally  believed  that  the  earlier  the  age  at 
which  menstruation  first  made  its  appearance,  the  earlier  also  would 
the  menopause  occur;  and  that,  on  the  other  hand,  the  later  the 
age  at  which  the  flow  began,  the  later  also  would  it  cease.  Virey 
summarized  this  opinion  in  the  saying:  prius  pubescentes  prius 
senescunt.  This  view  of  the  matter  is,  however,  true  only  in  respect 
of  the  influence  of  climate  upon  sexual  development.  In  a  cold 
climate,  a  woman  begins  to  menstruate  late  and  ceases  to  menstruate 
late ;  in  a  hot  climate  the  opposite  conditions  prevail.  But  if  we 
make  our  comparison  between  women  living  in  similar  conditions 
as  regards  latitude  and  climate,  we  find  that  Virey's  saying  is  far 
from  accurately  describing  the  facts. 

In  general,  and  climatic  influences  apart,  it  may  be  said  that  the 
earlier  in  any  woman  the  age  at  which  menstruation  first  occurs, 
the  later  will  be  the  age  at  which  menstruation  ceases. 

In  order  to  ascertain  the  influence  of  the  age  at  the  menarche 
upon  the  disappearance  of  menstrual  activity,  I  placed  in  compari- 
son first  the  cases  of  50  women  in  whom  menstruation  had  first 
appeared  between  the  ages  of  12  and  16  —  i.  e.,  cases  of  early 
menarche ;  and  secondly  the  cases  of  50  women  in  whom  menstrua- 


596  THE  SEXUAL  LIFE  OF  WOMAN. 

tion  had  begun  between  the  ages  of  16  and  20  —  i.  e.,  cases  of 
late  menarche.     The  result  was  the  following: 

In  the  50  women  in  whom  the  menarche  had  been  early,  the  meno- 
pause occurred 

At  ages  35  to  40  in     5  instances 

At  ageS  40  to  45  in  12  instances 

At  ages  45  to  50  in  25  instances 

At  ages  50  to  55  in    8  instances 

On  the  other  hand,  in  the  50  women  in  whom  the  menarche  had 
been  late,  the  menopause  occurred 

At  ages  35  to  40  in  9  instances 
At  ages  40  to  45  in  28  instances 
At  ages  45  to  50  in  10  instances 
At  ages  50  to  55  in  3  instances. 

Thus  whilst  among  the  women  in  whom  the  menarche  had  been 
late,  there  were  thirteen  only  who  continued  to  menstruate  until 
they  were  at  least  45  years  of  age ;  among  those  in  whom  the  men- 
arche had  been  early,  the  number  in  whom  menstruation  thus 
continued  up  to  the  age  of  45  or  beyond  was  33,  nearly  three  times 
as  great. 

On  the  other  hand,  in  those  cases  in  which  the  menarche  occurred 
at  an  abnormally  early  age,  i.  e.,  before  the  age  of  12  years,  the 
menopause  was  also  a  remarkably  early  one.  The  menopause  also 
came  on  very  early  in  women  in  whom  the  menarche  had  been  ex- 
tremely retarded,  until  the  age  of  20  and  upwards.  An  extremely 
early  and  an  extremely  late  menarche  alike  tend  to  be  followed  by 
a  premature  menopause. 

To  this  rule  there  are,  however,  exceptions,  and  we  occasionally 
meet  with  women  whose  reproductive  energies  are  so  powerful,  that 
the  menarche  occurs  at  an  unusually  early  age,  and  the  menopause 
is  postponed  to  an  age  considerably  beyond  the  average.  Thus, 
among  100  women  in  the  Salpetricre,  Raciborski  observed  29  in 
whom  menstruation  had  begun  at  the  exceptionally  early  age  of  12 
years,  and  who,  notwithstanding  this,  all  experienced  a  very  late 
menopause.  Three  of  them  were  still  menstruating  at  the  age  of 
57,  i  at  56,  2  at  52,  2  at  50,  3  at  48,  3  at  45,  and  13  at  an  age  less 
than  45. 

Brierre  de  Boismont  reports  the  case  of  a  woman  who  began  to 
menstruate  in  her  I2th  year;  she  married,  had  several  children,  and 
continued  to  menstruate  regularly  until  she  was  60  years  of  age. 

The  results  obtained  by  W.  Guy,  who  examined  a  series  of  250 
cases,  confirm  the  proposition  stated  above,  that  the  earlier  menstru- 
ation begins  (the  extremely  early  cases  being  excluded),  the  later 
it  ceases. 

According  to  Cohnstein,  who  bases  his  conclusions  upon  the  ob- 


SEXUAL  EPOCH  OF  THE  MENOPAUSE.  597 

servation  of  400  cases,  in  women  who  begin  to  menstruate  early,  the 
menopause  occurs  on  an  average  three  years  later,  than  in  women 
who  begin  to  menstruate  late.  Puech  also  states  that  menstruation 
lasts  longer  in  women  who  begin  to  menstruate  early,  than  in  those 
who  begin  to  menstruate  late.  According  to  Scanzoni,  in  women 
who  begin  to  menstruate  in  very  early  youth,  the  climacteric  age  is 
commonly  reached  earlier,  than  in  those  in  whom  puberty  occurs 
at  the  normal  age  —  commonly  between  the  ages  of  40  and  42  years. 
The  homology  between  the  pathological  states  which,  in  any 
particular  individual,  occur  at  the  respective  periods  of  the  menarche 
and  the  menopause,  is  sometimes  extremely  remarkable ;  the  very 
same  symptoms  by  which  the  first  appearance  of  menstruation  was 
preceded,  recur  as  antecedents  of  the  menopause.  This  is  seen  in 
the  case  of  certain  eczematous  conditions  of  the  skin,  of  dyspeptic 
manifestations,  epistaxis,  nervous  disturbances,  hysterical  and  epi- 
leptic seizures,  vasomotor  symptoms,  congestions,  cardiac  troubles, 
albuminuria,  etc.  Alibert  pointed  out  that  certain  skin  diseases  may 
appear  twice  only  during  life,  once  shortly  before  the  commence- 
ment of  menstruation,  and  the  second  time  shortly  before  the  cessa- 
tion of  menstrual  activity.  Brierre  de  Boismoirt  alludes  to  the  oc- 
currence of  hysteria  and  epilepsy  before  both  these  important  epochs 
in  a  woman's  life,  whilst  in  the  intervening  period  the  patient  had 
remained  entirely  free  from  such  troubles.  H.  Marsh  records  the 
observation  that  women  who  just  before  puberty  have  suffered  from 
repeated  attacks  of  epistaxis,  have  suffered  from  the  same  trouble 
as  a  predominant  symptom  of  the  climacteric  period.  Tilt  has  been 
in  several  cases  the  outbreak  of  numerous  furuncles  with  subsequent 
diarrhoea,  and  still  more  frequently  peculiar  attacks  of  severe 
vertigo,  occurring  in  women  just  before  the  two  critical  epochs  in 
her  life,  whilst  in  the  intervening  period  there  has  been  no  trace  of 
such  troubles,  either  in  connexion  with  menstruation,  with  the  puer- 
perium,  or  with  lactation. 

3.     The  Woman's  Sexual  Activity. 

An  important  influence  upon  the  early  or  late  onset  of  the  meno- 
pause is  exerted  by  the  degree  to  which  a  woman's  reproductive 
functions  have  been  exercised  during  the  menarche.  My  personal 
observations  have  shown  me  that  in  women  who  are  in  good  health 
and  of  a  powerful  build,  whose  menstrual  flow  has  always  beeti 
regular  and  sufficient  in  quantity,  whose  reproductive  organs  have 
been  adequately  and  properly  exercised,  who  have  had  a  physio- 
logical amount  of  sexual  intercourse,  have  given  birth  to  several 
children,  and  have  suckled  these  children,  the  cessation  of  the 
menstrual  flow  generally  occurs  much  later  than  in  women  in  whom 
the  conditions  of  the  sexual  life  have  been  the  opposite  of  those 


598  THE  SEXUAL  LIFE  OF  WOMAN." 

just  mentioned.  The  more  regular  menstruation  has  been,  and  the 
more  normal  the  deliveries,  the  later  does  the  menopause  ensue. 

Especially  striking  is  the  influence  of  the  number  of  deliveries 
upon  the  time  of  occurrence  of  the  menopause.  In  women  who 
have  given  birth  to  a  number  of  children,  menstruation  as  a  rule  con- 
tinues for  several  years  later  than  in  sterile  women,  or  in  those  who 
have  had  one  or  two  children  only.  If  a  woman  suckles  her  chil- 
dren, the  date  of  the  menopause  appears  also  to  be  postponed. 
Deliveries  late  in  life  seem  likewise  to  delay  the  onset  of  the  meno- 
pause, whereas  abortions  accelerate  its  occurrence.  If,  however, 
pregnancy  succeeds  pregnancy  at  extremely  short  intervals,  the 
menopause  is  likely  to  occur  early ;  the  same  result  is  brought  about 
by  sexual  intercourse  at  too  early  an  age.  The  menopause  occurs 
latest  in  women  who  have  begun  to  menstruate  early,  who  have 
married,  have  given  birth  to  more  than  three  children,  and  have 
been  delivered  of  their  last  child  at  full  term  when  38  to  42  years 
of  age. 

As  regards  the  500  women  previously  mentioned,  in  whom  I 
made  personal  observation  as  to  the  age  at  which  the  menopause 
occurred  and  the  circumstances  by  which  its  onset  was  influenced, 
the  effect  of  marriage  and  the  number  of  children  born  is  shown 
by  the  following  details : 

Of  the  48  women  in  whom  the  menopause  occurred  between  the 
ages  of  35  and  40,  16  were  unmarried,  6  married  and  childless.  18 
married  with  one  or  two  children,  8  married  with  more  than  two 
children. 

Of  the  141  women  in  whom  the  menopause  occurred  between  the 
ages  of  40  and  45,  3  were  unmarried,  4  married  and  childless,  46 
married  with  one  or  two  children,  88  married  with  more  than  two 
children. 

Of  the  177  women  in  whom  the  menopause  occurred  between  the 
ages  of  45  and  50,  i  was  unmarried,  2  were  married  and  childless, 
32  married  with  one  or  two  children,  142  married  with  more  than 
two  children. 

Of  the  89  in  whom  the  menopause  occurred  between  the  ages  of 
50  and  55,  none  were  unmarried,  none  were  childless,  19  were 
married  with  one  or  two  children,  70  were  married  with  more 
than  two  children. 

Of  the  17  women  in  whom  the  menopause  occurred  at  an  age 
above  55  years,  there  were  two  only  who  had  not  had  more  than 
two  children,  whilst  there  were  10  who  had  had  six  to  eight 
children. 

The  influence  of  lactation  is  shown  by  the  fact  that  in  the  case  of 
40  women  who  had  not  suckled  their  children,  the  mean  duration 


SEXUAL  EPOCH  OF  THE  MENOPAUSE.  599 

of  menstrual  activity  was  four  years  less  than  the  established  mean 
duration  of  27  years. 

4.     The  Social  Circumstances  of  the  Woman's  Life. 

The  conditions  in  which  a  woman  passes  her  life  are  not  without 
influence  upon  the  time  of  onset  of  the  menopause.  In  general  it 
may  be  said  that  among'  the  women  of  the  labouring  classes,  whose 
livelihood  is  so  often*  precarious,  and  who  are  apt  to  suffer  from 
habitual  physical  overwork,  menstruation  ceases  at  an  earlier  age 
than  among  the  women  of  the  well-to-do  classes  and  those  who  lead 
an  easier  life.  But  though  the  climacteric  thus  occurs  earlier  among 
the  lower  than  among  the  upper  classes,  the  difference  is  not  a 
considerable  one. 

According  to  Mayer's  calculation,  the  mean  age  at  which  men- 
struation ceases  is,  in  upper  class  women,  47.13  years,  in  lower  class 
women,  46.97  years.  Small  as  this  difference  appears,  amounting 
on  the  average  to  no  more  than  two  months,  it  must  not  be  for- 
gotten that  among  the  upper  classes,  menstruation  begins  earlier 
than  among  the  lower  classes,  by  an  amount  which  averages  1.31 
years.  Thus  the  total  duration  of  sexual  activity  is  almost  one  and 
a  half  years  longer  in  the  upper  than  in  the  lower  classes. 

5.     General  Constitutional  and  Pathological  Conditions. 

An  important  influence  upon  the  time  of  occurrence  of  the  meno- 
pause is  exerted  by  the  individual  and  hereditary  predisposition  of 
the  woman,  by  her  constitutional  state,  and  by  certain  illnesses 
from  which  she  has  suffered.  Women  who  by  inheritance  are  con- 
stitutionally weakly  and  delicate,  in  whom  the  menstrual  flow  has 
always  been  pale  and  scanty,  in  whom  the  intermenstrual  intervals 
have  been  excessive,  and  who  have  a  slender  habit  of  body,  attain  the 
climacteric  age  earlier  than  women  with  vigorous  bodily  develop- 
ment and  powerful  muscles,  with  large  breasts,  and  in  whom  men- 
struation has  always  been  regular  and  abundant.  Women  with  a 
great  tendency  to  obesity  cease  to  menstruate  earlier  than  women 
of  more  normal  proportions ;  blondes  earlier  than  brunettes ;  women 
of  phlegmatic  temperament  earlier  than  women  of  a  sanguine  and 
ardent  temperament. 

In  general  it  may  be  said,  that  all  influences  which  have  a 
weakening  effect  upon  the  feminine  organism,  tend  also  to  accel- 
erate the  onset  of  the  menopause:  such  are,  severe  labour,  great 
sorrow,  wearisome  occupations,  severe  menstrual  losses,  rapidly 
succeeding  pregnancies,  and  abortions ;  also  a  number  of  pathologi- 
cal general  states  shortly  to  be  discussed,  as  well  as  local  diseases 
of  the  reproductive  organs. 


6oo  THE  SEXUAL  LIFE  OF  WOMAN. 

Fritsch  points  out  that  menstruation  continues  to  a  later  age  in 
proportion  as  the  woman's  state  of  general  nutrition  is  a  good 
one.  He  also  asserts  that  women  with  a  very  large  uterus,  who 
have  always  had  an  abundant  menstrual  flow,  those  with  retroflex- 
ion,  with  hypertrophy  of  the  portio  vaginalis,  or  chronic  endocer- 
vicitis  and  endometritis,  and  those  with  small  myomata  which  have 
given  rise  to  no  marked  symptoms,  often  continue  to  menstruate 
far  beyond  the  usual  age. 

The  mean  duration  of  the  climacteric  phenomena,  from  the  com- 
mencement of  these  until  the  final  cessation  of  menstruation,  is 
about  two  years.  This  mean  is  made  up  of  extremely  wide  individ- 
ual variations ;  in  a  small  proportion  of  the  cases  the  climacteric 
manifestations  may  last  no  more  than  a  month  or  two,  whilst  at  the 
other  end  of  the  scale  we  meet  with  cases  in  which  the  duration 
extends  to  4,  6,  8,  and  even  18  years. 

In  considerably  more  than  half  of  all  the  cases,  however,  the 
duration  of  the  climacteric  manifestations  varies  between  six  months 
and  three  years.  Thus,  in  Tilt's  series  of  cases,  the  duration  of 
the  "  change  of  life  "  was 

6  months  in  12 . 07  of  all  cases 

1  year  in    22 . 64  of  all  cases 

2  years  in  18.62  of  all  cases 

3  years  in  9-43  of  all  cases 

6.     Premature,  Delayed  and  Sudden   Onset  of  the  Afenopause. 

In  exceptional  cases,  the  menopause,  instead  of  taking  place  be- 
tween the  fortieth  and  the  fiftieth  year  of  life,  occurs  at  an  abnor- 
mally early  or  an  abnormally  late  age. 

Premature  cessation  of  menstrual  activity,  in  the  third  or  the 
fourth  decennium  of  life  —  very  rarely  indeed  before  the  third 
decade  —  depends  in  part  upon  disturbances  of  metabolism  and  of 
haematopoiesis,  and  in  part  upon  diseases  of  the  female  reproduc- 
tive organs ;  in  some  cases,  however,  it  may  be  due  to  some  heredi- 
tary constitutional  peculiarity;  or  it  may  occur  suddenly,  in  conse- 
quence of  some  violent  shock  to  the  nervous  system. 

Among  the  disorders  of  metabolism  which  may  lead  to  a  prema- 
ture menopause,  excessive  adiposity,  lipomatosis  universalis,  occu- 
pies the  first  place.  Next  in  order  of  importance  come  a  chloro- 
anaemic  condition  of  the  blood,  pernicious  anaemia,  splenic  leuk- 
aemia, certain  of  the  acute  infectious  disorders  —  typhoid,  chol- 
era, scarlatina,  acute  articular  rheumatism, —  further  pulmonary 
tuberculosis,  diabetes  mellitus,  Graves'  disease,  Addison's  disease, 
and  myxoedema.  These  various  conditions  may  give  rise,  in  part 
by  infective  processes,  and  in  part  in  consequence  of  the  general 
cachectic  condition,  to  atrophy  of  the  ovaries  with  destruction  of  the 


SEXUAL  EPOCH  OF  THE  MENOPAUSE.  601 

graafian  follicles,  and  to  atrophic  processes  in  the  uterus,  and  these 
changes  lead  to  the  premature  cessation  of  menstrual  activity. 

Excessive  obesity  has  a  restrictive  influence  upon  ovarian  activ- 
ity, manifested  in  part,  as  already  mentioned,  by  the  occurrence  o£ 
sterility,  but  in  part  also,  in  very  obese  women,  by  the  onset  of  a 
premature  menopause.  Among  215  cases  of  extreme  obesity  in 
women,  I  found  49  in  which  the  menopause  occurred  at  a  remark- 
ably early  age.  In  these  cases  the  menopause  occurred  at  the 
following  age : 

In     I  woman  at  the  age  of '. .  .  17  years 

In  14  women  at  the  age  of 20  to  25  years 

In  1 1  women  at  the  age  of 25  to  30  years 

In     9  women  at  the  age  of 30  to  35  years 

In  14  women  at  the  age  of 35  to  40  years 

In  none  of  these  cases  did  the  local  examination  of  the  reproductive 
organs  disclose  the  existence  of  any  noteworthy  disease. 

Of  the  diseases  of  the  genital  organs  which  are  competent  to  give 
rise  to  a  premature  cessation  of  menstrual  activity,  the  most  im- 
portant are  the  puerperal  infective  processes  and  other  inflammatory 
states  of  the  reproductive  organs,  with  their  results — chronic  me- 
tritis,  perimetritic  and  parametritic  exudations,  chronic  oophoritis, 
atrophy  of  the  uterus  and  the  ovaries. 

After  infective  puerperal  processes,  it  sometimes  happens  that 
there  is  far-reaching  destruction  of  the  uterine  musculature,  degen- 
eration of  the  uterine  mucosa,  permanent  and  irreparable  atrophy 
of  the  uterus,  and  suppuration  and  atrophy  of  the  ovaries  —  con- 
ditions which  result  in  an  extinction  of  menstrual  activity.  A  sim- 
ilar result  may  ensue  upon  the  persistent  and  long-continued 
pressure  upon  the  uterus  and  the  ovaries  of  a  large  mtra-pelvic 
exudation ;  such  exudation  being  commonly  post-puerperal,  but  oc- 
casionally arising  in  the  absence  of  pregnancy.  Further,  according 
to  Freund,  chronic  atrophic  parametritis  may  give  rise  to  an  incur- 
able atrophy  of  the  uterus,  by  interference  with  the  circulation  of 
the  blood  through  the  broad  ligaments,  and  consequent  impairment 
of  the  nutrition  of  the  uterus.  Gonorrhoeal  inflammation  may  also 
lead  to  the  termination  of  menstrual  activity,  when  it  gives  rise  to 
intramural  inflammatory  deposits  in  the  uterus,  and  to  chronic  in- 
flammatory processes  in  the  ovaries.  Tumours  of  the  uterus  and  the 
uterine  annexa  may  likewise  induce  a  premature  menopause. 

We  also  meet  with  cases  in  which  after  a  pregnancy,  to  all  ap- 
pearance normal  in  its  course  and  termination,  a  premature  meno- 
pause results.  To  this  category  belong  the  cases,  according  to 
Kleimvachter  of  no  extreme  rarity,  in  which  perfectly  healthy 
women  are  attacked  by  profuse  uterine  haemorrhage  during  the 


a    OF 

utr 


602  THE  SEXUAL  LIFE  OF  WOMAN. 

course  of  a  normal,  full-term  labour,  or  during  miscarriage ;  subse- 
quently, though  the  lying-in  period  is  passed  without  further  mis- 
adventure or  abnormality,  and  in  the  absence  of  lactation,  the  patient 
becomes  permanently  amenorrhoeic.  The  normal  involution  of  the 
uterus  passes  on  into  hyperinvolution,  and  ultimately  complete 
atrophy  of  uterus  and  ovaries  results.  In  some  cases,  moreover,  such 
hyperinvolution  with  consecutive  atrophy  follows  normal  labour  or 
abortion  without  the  occurrence  of  any  excessive  haemorrhage. 

Much  more  frequently  do  we  find  that  rapidly  successive  preg- 
nancies, with  long-continued  exercise  of  the  lacteal  function,  in 
badly  nourished,  anaemic  women,  give  rise  to  a  premature  meno- 
pause, due  to  permanent  atrophy  of  the  uterus  and  ovaries,  which 
are  in  such  cases  so  poorly  supplied  with  blood.  This  "  lactation- 
atrophy  "  is  described  by  Frommel  and  Thorn  as  a  concentric 
atrophy  first  of  all  affecting  the  corpus  uteri,  and  to  this,  if  the 
disease  advances,  there  succeeds  a  general  atrophy  of  the  muscular, 
connective,  and  fatty  tissues  of  the  parametrium,  the  vagina,  the 
pelvic  floor,  and  ultimately  of  the  ovaries,  leading,  when  perma- 
nent, to  a  premature  menopause. 

Trauma  of  the  genital  organs  may  also  lead  to  uterine  atrophy  and 
to  premature  menopause. 

By  many  authors  it  is  believed  that  too-early  marriage,  sexual 
excesses,  and  prostitution,  may  be  the  cause  of  cessatio  praecox.  In 
some  cases,  there  is  unquestionably  a  hereditary  predisposition  to 
a  premature  climacteric,  since  the  mothers  of  the  women  in  whom 
it  occurs  have  themselves  been  similarly  affected.  In  the  remarkable 
case  which  came  under  my  own  observation,  of  a  woman  from 
Smyrna,  there  was  hereditary  predisposition.  This  woman  began 
to  menstruate  when  12  years  of  age;  menstruation  was  always 
scanty;  she  married  when  15  years  of  agt*  and  she  ceased  to  men- 
struate for  ever  at  the  age  of  19.  In  other  cases  we  find  there  is 
a  family  tendency  for  menstruation  to  be  delayed  in  its  first  appear- 
ance to  a  comparatively  advanced  age,  and  to  cease  at  the  usual  time. 

In  cases  of  cessatio  mensium  praecox  (unless  the  failure  of  men- 
struation has  been  quite  a  sudden  one),  and  after  the  premature 
menopause  is  fully  established,  we  find  in  the  uterus  and  the  ovaries 
anatomical  changes  similar  to  those  met  with  after  the  natural 
climacteric  —  diminution  in  the  size  of  the  uterus  with  thinning  of 
its  walls,  density  and  firmness  of  the  tissues  of  the  organ,  smallness 
and  a  soft  consistency  of  the  ovaries ;  sometimes,  also,  the  mammae 
are  atrophic. 

In  cases  of  premature  menopause,  the  troubles  attending  the 
change  are  commonly  more  severe  and  more  enduring  than  those 
that  occur  at  the  natural  menopause.  Especially  is  this  the  case 
when  the  premature  menopause  is  quite  a  sudden  occurrence,  but  this 


fJ3JJGTj 


SEXUAL  EPOCH  OF  THE  MENOPAUSE.  603 

phenomenon  is  rare.  Most  commonly  the  premature  menopause  is 
gradual  in  onset;  the  flow  becomes  more  scanty  month  by  month, 
until  at  last  it  fails  altogether  to  appear.  Irregularity  in  the  men- 
strual rhythm  is  not  often  seen  in  such  cases.  Early  senescence  is 
exceptional  in  these  women  in  whom  a  premature  menopause  occurs. 
Emaciation,  greyness  of  the  hair,  wrinkling  of  the  skin,  the  growth 
of  hairs  on  the  face,  etc.,  are  not  usually  associated  with  the  atrophy 
of  the  reproductive  organs ;  the  physionognomy  and  figure  of 
women  with  cessatio  praecox  being  usually  similar  to  those  seen  in 
women  of  corresponding  age  in  whom  menstruation  still  continues. 

Tilt  enquired  regarding  the  cause  of  cessatio  praecox  in  27  in- 
stances, with  the  following  results : 

In  3  instances,  parturition  and  lactation. 

In  I  instance,  abortion. 

In  2  instances,  a  fall  on  the  sacrum  during  menstruation. 

In  2  instances,  suppression  of  menstruation  from  chill. 

In  I  instance,  haemorrhage  from  the  arm  during  menstruation. 

In  i  instance,  celebration  of  nuptials  during  menstruation. 

In  2 'instances,  severe  medicinal  purgation. 

In  2  instances,  cholera. 

In  2  instances,  rheumatic  fever. 

In  2  instances,  febrile  bronchitis. 

In  9  instances,  intermittent  fever. 

In  i  case  Tilt  saw  cessation  of  menstruation  occur  at  the  age  of 
29,  in  consequence  of  metritis.  Atlee,  in  15  cases  of  ovarian  tumour, 
saw  the  menopause  occur  at  ages  of  30,  39,  40  and  42.  Pnech  saw 
a  premature  menopause  at  the  age  of  30  in  3  cases,  in  each  a  sequel 
of  cholera.  Blondel  reports  a  case  of  cessatio  praecox  after  pro- 
longed galactorrhoea,  although  the  woman  had  not  suckled  her 
infant;  Gottschalk  and  Rokitansky,  cases  following  injury  to  the 
cervix  uteri;  Kiivisch,  Simpson,  and  Kleimvachtcr,  cases  following 
full-time,  normal  deliveries,  in  which,  however,  severe  losses  of 
blood  had  taken  place. 

Courty  and  Brierre  de  Boismont  report  cases  in  which  the  meno- 
pause occurred  as  early  as  the  age  of  21 ;  Mayer,  2  cases  at  the  age 
of  22;  Kricgcr,  i  case  at  23;  Brierre  de  Boismont,  i  case  at  24; 
Mayer,  2  cases  at  25 ;  Brierre  de  Boismont,  i  case  at  26,  and  i  case 
at  27 ;  Guy  and  Tilt,  each  i  case  at  the  age  of  27 ;  Brierre  de  Bois- 
mont, Courty,  and  Guy,  each  i  case  at  the  age  of  28;  Brierre  de 
Boismont,  Courty,  and  Mayer,  each  I  case  at  the  age  of  29;  Guy  and 
Tilt,  each  i  case  at  the  age  of  30;  and  Mayer,  5  cases  at  the  age 
of  30. 

An  unusually  late  climacteric,  the  continuance  of  menstruation 
beyond  the  age  of  50  years,  is  not  an  extremely  rare  occurrence,  but 


604  THE  SEXUAL  LIFE  OF  WOMAN. 

is  less  often  seen  than  cessatio  praecox.  There  is,  however,  in  these 
cases  a  difficulty  which  must  not  be  underestimated,  namely,  to  dis- 
tinguish between  a  genuine  menstrual  bleeding  and  the  other  uterine 
haemorrhages  which  are  common  precisely  at  this  age  of  life,  due 
either  to  textural  changes  in  the  uterus,  or  to  neoplasmata  —  more 
especially  because  in  these  non-menstrual  haemorrhages  also  a  cer- 
tain periodicity  may  often  be  detected.  When  on  careful  examina- 
tion no  abnormality  can  be  discovered  in  the  reproductive  organs, 
when  the  bleeding  in  question  recurs  at  the  intervals  and  in  associa- 
tion with  the  general  symptoms  to  which  the  woman  thus  affected  has 
been  accustomed  during  her  previous  menstruations,  and  when  the 
amount  of  blood  discharged  is  not  abnormal,  it  is  permissible  to 
conclude  that  we  have  to  do  with  a  persistence  of  true  menstruation, 
even  though  the  woman  has  some  time  since  completed  the  fifth 
decennium  of  her  life.  In  some  women,  in  fact,  the  reproductive 
system_is  so  energetic,  that  ovulation  continues  to  an  age  for  beyond 
the  average,  and  such  women  are  to  be  regarded  as  sexually 
long-lived. 

Although  the  instances  of  protracted  menstruation  contained  in 
the  older  literature  of  the  subject  are  open  to  suspicion,  owing  to 
the  fact  that  at  that  time  it  was  not  possible  to  distinguish  with 
certainty  between  menstrual  and  pathological  uterine  haemorrhage, 
quite  recently  numerous  incontestible  cases  of  enduring  sexual 
vitality  have  been  put  on  record. 

I  have  myself  seen  no  less  than  106  cases  in  which  the  menopause 
did  not  occur  until  after  the  age  of  50  years;  among  these  there 
were  4  in  which  the  age  at  the  menopause  was  56;  5  in  which  it 
was  57;  2  in  which  it  was  58;  I  in  which  it  was  59;  and  I  in  which 
it  was  60.  Tilt  records  128  cases  of  menopause  occurring  after  50; 
among  these  there  were  4  in  which  the  woman  was  56  when  men- 
struation ceased ;  2  who  were  57 ;  4  who  were  58 ;  I  who  was  59 ;  I 
who  was  60;  and  2  who  were  61.  Courty  reports  a  case  in  which 
menstruation  persisted  after  the  age  of  65 ;  Mayer,  3  cases  of  meno- 
pause at  64;  Beigel,  2  cases,  i  in  which  menstruation  continued  to 
the  age  of  65,  the  other,  to  the  age  of  72.  Klcinwachtcr  observed 
33  cases  in  which  menstruation  continued  to  an  age  varying  from 
50  to  57  years.  Emmet,  in  the  year  1886,  published  the  case  of  a 
woman  who  was  then  70  years  old,  and  who  at  this  advanced  age 
continued  to  menstruate  regularly. 

That  not  every  case  in  which  after  the  age  of  50  years  there 
is  recurrent,  more  or  less  periodic,  haemorrhage  from  the  genital 
organs,  is  to  be  regarded  as  an  instance  of  delayed  menopause,  we 
are  taught  by  the  records  of  post  mortem  examination  in  several 
cases  of  the  kind.  Scanzoni  reports  the  case  of  a  woman  who  at 
the  age  of  60  was  affected  with  a  fairly  regular  periodic  discharge 


SEXUAL  EPOCH  OF  THE  MENOPAUSE.  605 

of  blood  from  the  vagina.  During  one  of  these  haemorrhages,  she 
died  of  pneumonia,  and  the  autopsy  showed  that  the  ovaries  were 
completely  atrophied  and  transformed  into  dense  scar  tissue,  and 
contained  no  trace  of  corpus  luteum  or  of  fresh  extravasation  of 
blood,  whilst  in  the  upper  part  of  the  cervical  canal  there  were  two 
mucous  polypi  each  of  about  the  size  of  a  bean.  In  another  case, 
that  of  a  woman  64  years  of  age,  periodic  losses  of  blood,  at  inter- 
vals of  from  three  to  four  weeks,  continued  to  the  time  of  her  death. 
This  woman  suffered  from  mitral  valvular  insufficiency,  and  it  was 
clear  that  the  haemorrhages  had  been  due  to  the  venous  engorge- 
ment consequent  upon  imperfect  compensation.  The  ovaries  were 
completely  atrophied,  and  showed  no  trace  of  any  recent  maturation 
of  ova ;  the  uterus  was  enlarged,  the  mucous  membrane  hyperaemic, 
and  the  cavity  contained  a  recent  clot. 

Not  infrequently,  the  haemorrhages  attributed  to  the  persistence 
of  menstruation  are  really  due  to  senile  arterio-sclerosis — to  rigidity 
and  brittleness  of  the  uterine  arteries ;  in  other  cases  they  arise  from 
varicosity  of  the  veins  of  the  cervical  canal.  A  common  cause  of 
such  bleedings  from  the  genital  passage  in  comparatively  advanced 
life,  is  to  be  found  in  the  growth  of  uterine  myomata. 

To  myoma  uteri  we  must  attribute  a  part,  though  by  no  means  all, 
of  the  cases  in  which  menstruation  seems  to  recur  some  years  after 
the  menopause  has,  to  all  appearance,  been  fully  established.  In 
most  of  these  cases,  indeed,  we  have  to  do  with  pathological  haemor- 
rhages, the  cause  of  which  is,  however,  but  too  often  obscure.  Still, 
cases  certainly  occur  in  which,  two  or  three  years  or  even  longer 
after  the  menopause,  some  unknown  stimulus  leads  to  the  regular 
recurrence  of  menstruation.  The  possibility  of  such  an  occurrence 
is,  in  my  opinion,  fully  proved  by  post  mortem  examinations  of  the 
bodies  of  elderly  women  in  whom  the  menopause  has  been  fuly  es- 
tablished and  yet  the  ovaries  are  found  to  contain  follicles  of  various 
degrees  of  ripeness,  and  also  fresh  corpora  lutea — signs  that  ovu- 
lation  may  persist  for  a  considerable  time  after  the  complete  cessa- 
tion of  menstruation.  Another  proof  of  the  last  fact  is  the  well 
known  experience  that  women  who  have  some  time  ago  ceased  to 
menstruate,  may  nevertheless  become  pregnant.  Waldeyer,  in- 
deed, asserts  that  when  four  years  have  elapsed  since  the  menopause, 
follicles  are  never  to  be  found  in  the  ovaries,  but  this  negative  ex- 
perience is  not  decisive,  especially  as  regards  the  cases  in  which 
regular  menstruation  is  resumed  some  time  after  the  occurrence  of 
a  premature  menopause. 

I  have  myself  seen  several  cases  in  which  the  menopause  occurred 
at  35,  38,  39,  and  42  years,  respectively;  3,  4,  or  5  years  later,  as  a 
result  of  hydropathic  treatment,  regular  menstruation  recurred.  In 


606  THE  SEXUAL  LIFE  OF 

one  case,  a  woman  who  had  ceased  to  menstruate  ten  years  before, 
gave  birth  to  a  child  at  the  age  of  45. 

Numerous  indisputable  cases  of  this  kind  are  reported  in  the  re- 
cent literature  of  the  subject.  Kricgcr  had  under  his  personal  ob- 
servation a  woman  of  a  robust  habit  of  body,  in  whom  menstruation 
ceased  at  the  age  of  48  years,  her  eighth  child  having  been  born 
fifteen  years  before.  Two  years  later  irregular  menstruation  re- 
curred, and  on  the  cessation  of  these  haemorrhages,  it  appeared  that 
the  woman  was  once  more  gravid;  she  was  delivered  at  full  term 
of  a  girl.  Mayer  observed  the  following  case:  A  strong  working- 
class  woman  33  years  of  age  had  begun  to  menstruate  regularly 
when  13  years  old;  between  the  ages  of  17  and  28  she  gave  birth  to 
five  children,  and  in  addition  had  one  miscarriage  when  19  years 
old.  Widowed  at  the  age  of  29,  she  fell  ill,  and  on  examination  the 
uterus  was  found  to  be  small  and  relaxed,  whilst  the  vaginal  portion 
of  the  cervix  was  reduced  to  a  mere  rudiment.  Since  she  had  been 
22  years  of  age  she  had  had  persistent  leucorrhoea,  but  no  trace  of 
menstrual  haemorrhage ;  yet  since  that  age  she  had  had  three  chil- 
dren. Renaudin  delivered  a  woman  61  years  of  age,  who  had 
ceased  to  menstruate  12  years  earlier.  Meissner  reports  a  case  in 
which  a  woman  first  began  to  menstruate  at  the  age  of  20,  had  her 
first  child  when  47  years  old,  and  gave  birth  to  the  last  of  her  eight 
children  when  60  years  of  age. 

The  sudden  and  permanent  cessation  of  menstruation,  whether  at 
the  normal  climacteric  age,  or  earlier  in  life,  is  always  a  pathologi- 
cal occurrence.  As  compared  with  the  normal,  gradual  disappear- 
ance of  menstruation,  associated  with  the  usual  climacteric  symp- 
toms, such  a  sudden  extinction  of  menstrual  activity  is,  moreover, 
quite  rare.  When  it  does  occur,  the  cause  is  to  be  found  in  one  of 
various  pathological  general  states,  such  as  one  of  the  acute  infec- 
tious disorders,  or  some  other  exhausting  disease,  or  sometimes  in 
some  local  disease  of  the  reproductive  organs;  occasionally,  how- 
ever, it  may  occur  in  perfect  health,  in  consequence  of  some  power- 
ful physical  or  mental  stimulus,  such  as  a  severe  blow  or  intense 
fright. 

This  sudden  menopause  has  been  observed  after  severe  labour  or 
abortion  with  profuse  haemorrhage,  or  after  cholera  or  typhoid ;  \ve 
must  assume  that  in  such  cases  the  anaemia  of  the  genital  organs 
has  disturbed  the  function  of  ovulation ;  whilst  in  cases  due  to  mental 
shock,  the  interference  with  ovulation  must  be  through  the  interme- 
diation of  the  nervous  system.  Frequently,  of  course,  in  these 
cases,  the  sudden  menopause  is  also  a  premature  one. 

Tilt  reports  a  case  in  which  a  sudden  menopause  ensued  upon 
phlebotomy  during  menstruation ;  several  cases  also  in  which  women 
at  ages  varying  from  30  to  34,  or  39  years,  ceased  to  menstruate 


SEXUAL  EPOCH  OF  THE  MENOPAUSE.  607 

suddenly  and  permanently  in  consequence  of  grief  at  the  unexpected 
death  of  the  husband;  and  another  case  of  sudden  menopause  due 
to  a  fall  down  stairs.  Courty  reports  three  cases  of  sudden  meno- 
pause at  the  age  of  30,  consequent  upon  an  attack  of  cholera. 
Dusourd  has  seen  three  cases  in  which,  in  women  aged  40  to  43 
years,  severe  haemorrhoidal  bleeding  was  followed  by  sudden  and 
permanent  cessation  of  menstruation.  Mayer  reports  the  case  of  a 
delicate  middle-class  woman  34  years  of  age,  who  had  begun  to 
menstruate  at  the  age  of  14,  had  married  at  the  age  of  20,  and  at 
the  age  of  21  after  a  normal  delivery,  ceased  for  ever  to  menstruate; 
and  another  case  of  a  working-class  woman  34  years  of  age  who 
first  menstruated  at  the  age  of  13  years,  married  at  the  age  of  20, 
had  two  children  in  rapid  succession,  and  finally  ceased  to  menstru- 
ate, in  consequence  of  a  fright,  at  the  age  of  30  years.  Kriegcr 
reports  the  case  of  a  very  nervous  woman  who  first  menstruated  at 
the  age  of  thirteen,  and  in  whom  at  the  age  of  23  a  sudden  meno- 
pause ensued  upon  a  nervous  attack;  in  another  case  reported  by 
the  same  observer,  a  sudden  menopause  occurred  in  a  delicate 
woman  41  years  of  age  owing  to  her  husband's  death  —  this  woman 
had  previously  experienced  six  months  amenorrhoea  in  consequence 
of  sorrow  at  the  death  of  one  of  her  children.  The  following  re- 
markable case  is  reported  by  Brierre  de  Boismont:  A  sempstress 
began  to  menstruate  at  the  age  of  13  years ;  she  married  very  soon 
after  this,  and  gave  birth  to  four  children,  the  last  when  21  years 
of  age.  In  the  course  of  the  following  year  there  was  a  fire  in  the 
house,  and  owing  to  this  fright  a  sudden  menopause  occurred.  Sim- 
ilar cases  have  been  reported  quite  recently  by  Bossi  and  Walter. 

The  harmful  influence  which  the  occurence  of  a  sudden  meno- 
.pause  exercises  upon  the  general  condition  of  the  woman  who 
experiences  it,  is  manifested  chiefly  by  violent  circulatory  disturb- 
ances, hyperaemia  and  congestion  of  the  brain,  lungs,  and  abdominal 
organs,  and  by  states  of  excitement  and  depression  of  the  nervous 
system.  Of  the  vicarious  haemorrhages  which  are  apt  to  ensue  upon 
such  a  sudden  menopause,  we  have  already  spoken. 

Generally  speaking,  women  in  middle  life,  in  whom  the  whole 
organism  is  accustomed  to  the  onset  and  decline  of  the  menstrual 
hyperaemia,  endure  the  functional  disturbances  induced  by  a  sudden 
and  complete  cessation  of  menstruation  much  more  easily  than 
women  who  have  already  entered  upon  the  climacteric  age,  or  have 
nearly  attained  that  age.  The  climacteric  age  is  one  in  which  women 
are  already  predisposed  to  circulatory  disturbances  in  the  pelvic 
organs,  and  it  will  readily  'be  understood  that  in  them  the  sudden 
interruption  of  the  menstrual  haemorrhages  will  have  more  serious 
consequences  than  in  women  in  the  prime  of  their  sexual  life,  and 
therefore  endowed  with  a  greater  power  of  resisting  disturbances 
of  the  normal  functions. 


608  THE  SEXUAL  LKFE  OF  WOMAN. 

PATHOLOGY  OF  THE  MENOPAUSE. 
Diseases  of  the  Genital  Organs. 

Among  the  commonest  of  the  symptoms  of  the  sexual  epoch  of 
the  menopause  is  menorrhagia.  It  occurs  especially  in  plethoric 
women,  in  those  who  during  the  prime  of  their  sexual  life  have 
been  accustomed  to  menstruate  abundantly,  and  in  those  who  have 
given  birth  to  many  children  or  had  many  miscarriages;  but  it  is 
seen  also  in  weakly  and  delicate  individuals,  in  whom  the  tissues  of 
the  genital  organs  have  become  extremely  flaccid  and  loose  in 
texture.  A  luxurious  mode  of  life,  more  especially  a  free  consump- 
tion of  alcoholic  beverages,  and  also  frequent  sexual  intercourse 
during  the  climacteric  period,  appear  to  favour  the  occurrence  of 
menorrhagia  at  this  epoch. 

Not  infrequently,  menorrhagia  is  the  first  sign  of  the  commence- 
ment of  the  climacteric,  menstruation  having  been  hitherto  regular, 
and  not  excessive  in  amount.  Generally,  when  this  climacteric 
menorrhagia  begins,  the  intervals  also  become  shorter,  the  menstrual 
period  being  reduced  to  three  or  even  two  weeks.  At  times,  how- 
ever, the  more  profuse  menstruation  recurs  at  longer  intervals,  six 
weeks,  two  months,  or  even  longer.  In  any  case,  the  occurrence  at 
the  climacteric  age  of  a  severe  or  atypical  haemorrhage,  renders  it 
the  imperative  duty  of  the  physician  to  undertake  a  local  examina- 
tion of  the  genital  organs;  for  it  is  necessary  to  ascertain  without 
delay  whether  such  a  haemorrhage  is  a  true  climacteric  phenomenon, 
or  whether  it  is  due  to  some  actual  disease  of  the  reproductive 
organs  —  a  neoplasm,  or  the  like. 

If  the  haemorrhage  is  due  solely  to  the  change  of  life,  the  vaginal 
portion  of  the  cervix  will  usually  be  found  soft  and  flaccid,  bleeding 
readily  on  slight  injury,  and  sometimes  eroded ;  there  is  generally 
associated  leucorrhoea.  This  relaxation  and  loss  of  firmness  in  the 
uterine  tissues  at  the  time  of  the  menopause  is  the  cause  of  the  pre- 
disposition to  excessive  haemorrhage.  An  additional  cause  exists 
in  the  circulatory  disturbances  in  the  pelvic  organs.  We  presume 
that  women  affected  with  menorrhagia  at  this  time  of  life  suffer 
from  some  persistent  disturbance  in  the  region  of  the  inferior  vena 
cava,  whereby  the  outflow  of  blood  from  the  veins  of  the  pelvis  is 
hindered,  and  a  chronic  condition  of  stasis  in  the  uterus  is  condi- 
tioned. Hence  arises  distension  of  the  vessels  of  the  uterine  mucous 
membrane,  and  this  rhexis  is  relieved  by  the  excessive  haemorrhages. 
In  these  considerations  lies  the  explanation  of  the  fact  that  women 
who  have  had  many  children  or  many  miscarriages,  are  especially 
prone  to  suffer  from  climacteric  menorrhagia ;  and  also  women  who 
for  any  reason  are  predisposed  to  intra-abdominal  stasis. 


SEXUAL  EPOCH  OF  THE  MENOPAUSE.       609 

Another  cause  of  climacteric  menorrhagia  is  to  be  found  in  the 
frequent  occurrence  at  this  epoch  of  advanced  arterio-sclerotic 
changes  in  the  uterine  blood  vessels,  the  disease  being  in  some  cases 
limited  to  the  uterine  arteries,  and  in  others  part  of  a  general 
arterial  degeneration.  The  blood  may  be  derived  from  ruptured 
sclerotic  capillaries  of  the  mucous  membrane ;  but  in  other  cases  it 
exudes  in  consequence  of  passive  hyperaemia,  without  actual  rupture 
of  the  bloodvessels.  To  such  haemorrhages  .from  atheromatous 
vessels  we  must  refer  many  of  the  attacks  of  uterine  haemor- 
rhage that  occur  in  elderly  women,  such  as  were  formerly,  before 
their  true  nature  was  understood,  commonly  regarded  as  instances 
of  a  very  late  return  of  menstruation.  By  careful  examination  the 
exact  source  of*  the  blood  can  often  be  detected  in  such  cases. 

According  to  Thcilhaber,  one  cause  of  the  haemorrhages  occurring 
at  the  climacteric  is  to  be  found  in  the  atrophy  of  the  uterine  muscle 
which  takes  place  at  this  period  of  life.  Except  during  pregnancy 
and  the  puerperium,  the  uterus  is  usually  in  a  state  of  moderate  con- 
traction; during  the  height  of  the  menstrual  flux,  however,  the 
uterus  is  relaxed.  Then,  as  contraction  of  the  muscle  sets  in,  the 
menstrual  hyperaemia  and  consequent  haemorrhage  are  gradually 
brought  to  an  end.  When  this  contraction  is  insufficient,  the 
hyperaemia  and  swelling  of  the  uterus  are  more  enduring.  In 
association  with  the  atrophy  of  the  uterine  muscle  at  the  climacteric, 
there  usually  occurs  ?.  notable  diminution  in  the  size  of  the  uterine 
vessels,  so  that,  notwithstanding  the  diminished  strength  of  the 
muscular  contractions,  any  excessive  loss  of  blood  is  prevented. 
But  if  this  diminution  in  the  calibre  of  the  vessels  fails  to  take  place, 
the  atony  of  the  uterine  muscle  leads  to  hyperaemia,  to  haemorrhage, 
and  often,  in  addition,  to  oedema  of  the  organ,  with  elongation  and 
thickening  of  its  walls  —  hyperplasia  uteri  preclimacterica. 

Among  diseases  of  the  uterus  which  during  the  climacteric  may 
give  rise  to  severe  haemorrhage,  and  may  lead  to  the  mistaken 
opinion  that  menstruation  still  continues,  we  must  in  the  first  place 
mention  carcinomatous  disease  of  the  cervix  and  of  the  body  of 
the  uterus ;  next  in  importance  come  myoma  and  fibrous  polypi ;  less 
frequent  causes  of  such  haemorrhages  are  fungous  endometritis, 
erosions,  mucous  polypi,  prolapse  of  the  uterus,  and  ovarian  cystoma. 

The  climacteric  age  gives  rise  to  a  predisposition,  not  only  to 
bleeding,  but  also  to  other  pathological  changes  in  the  reproductive 
organs.  We  can  'by  no  means  endorse  the  opinion  of  Currier  —  one 
long  ago  expressed  also  by  Bricrre  dc  Boismont  —  that  women  dur- 
ing the  sexual  epoch  of  the  menopause  are  less  disposed  to  diseases 
of  all  kinds,  and  among  them  to  diseases  of  the  genital  organs, 
than  younger  women,  for  the  reason  that  their  tissues  are  endowed 
with  less  vitality,  and  are,  therefore,  more  resistent  to  all  the  causes 
39 


610  THE  SEXUAL  LIFE  OF  WOMAN. 

of  disease.  On  the  contrary,  the  number  of  pathological  disorders 
liable  to  affect  the  reproductive  organs  precisely  at  this  period  of 
life,  is  strikingly  large.  Among  my  500  cases  of  women  at  the 
climacteric  age,  there  were  440  who  complained  of  such  symptoms, 
the  diseases  from  which  they  suffered  being,  in  order  of  frequency : 

Profuse   haemorrhages  in 286  cases 

Chronic  metritis  in 79  cases 

Leucorrhoea  in 327  cases 

Displacements  of  the  uterus 117  cases 

viz.,  prolapsus  in 65  cases 

anteflexion  and  retroflexion  in 52  cases 

Genital  pruritus  in 46  cases 

Vaginismns  in 12  cases 

Carcinoma  uteri  in 3  cases 

Myoma  uteri  in , 5  cases 

Tumor  mammae  in 8  cases 

I  need  hardly  point  out  that  in  many  individuals  more  than  one 
of  these  diseases  were  present  at  the  same  time. 

The  most  obvious  feature  of  these  statistics  is  the  extraordinary 
frequency  of  uterine  haemorrhage  and  of  leucorrhoea  in  climacteric 
women.  The  former  condition  was  present  in  more  than  half  my 
cases;  the  latter  actually  in  three-fourths. 

The  same  two  pathological  states  were  also  those  most  frequently 
recorded  in  Tilt's  statistics.  This  author,  in  446  women  at  the 
climacteric,  found  the  following  diseases  of  the  reproductive  ap- 
paratus : 

Haemorrhages  in    138  cases 

Leucorrhoea  recurring  at  irregular  intervals  in 146  cases 

Leucorrhoea  recurring  monthly  in 12  cases 

Remittent  menstruation  in 33  cases 

Vaginitis  in  4  cases 

Follicular  inflammation  of  the  vulva  in 10  cases 

Inflammation  of  the  labia  in , 4  cases 

Ulceration  of  the  cervix  uteri  in 9  cases 

Prolapsus  uteri  in 5  cases 

Uterine  polypi  in 4  cases 

Fibrous  tumours  of  the  uterus  in 4  cases 

Cancer  of  the  uterus  in 4  cases 

Chronic  ovarian  tumours  in 3  cases 

Irritation  and  swelling  of  the  breasts  in 14  cases 

Lacteal  or  gelatinous  secretion  in  breasts  in 2  cases 

Hard,  non-malignant  tumour  of  the  breast  in 2  cases 

Chancre  of  the  breast  in I  case 

Frequent  sedimentation  in  the  urine  in 49  cases 

Difficult  and  painful  micturition  in 9  cases 

Incontinence  of  urine  in 4  cases 

Haematuria  in  I  case 

Erectile  tumour  of  the  urinary  meatus  in. 2  cases 

Perineal  abscess  in 2  cases 

Chronic  metritis  and  endometritis  come  under  observation  with 
considerable  frequency  during  the  climacteric  age,  but  as  a  rule 


SEXUAL  EPOCH  OF  THE  MENOPAUSE.  611 

these  diseases  have  originated  during  the  period  of  sexual  maturity, 
and  in  exceptional  instances  only  does  the  cessation  of  the  menses 
appear  to  be  the  etiological  starting  point  of  these  disorders.  In 
fact,  this  occurs  only  when  the  menopause  is  premature,  or  when 
it  is  quite  sudden  in  onset,  whether  this  be  due  to  noxious  influences 
or  to  constitutional  disorder.  For  the  menstrual  process  quite  nor- 
mally gives  rise  to  a  certain  congestion  of  the  genital  organs;  and 
should  menstruation  be  suddenly  suppressed,  the  blood-stasis  in  the 
uterus  becomes  so  extreme  that  morbid  tissue  changes  are  very 
likely  to  ensue.  And  when  chronic  metritis  has  occurred  before, 
the  congestion  and  stasis  in  the  uterus  at  the  climacteric  will  usually 
suffice  to  light  up  the  inflammatory  process  afresh.  This  is  the  ex- 
planation of  the  fact  that  symptoms  of  slight  metritis  make  their 
appearance  at  the  very  beginning  of  the  climax,  manifested  by  thick- 
ening of  the  corpus  uteri  and  of  the  portio  vaginalis  of  the  cervix, 
by  swelling  and  softening  of  the  mucous  membrane,  and  by  abun- 
dant secretion.  In  those  who,  either  after  full-term  delivery  or 
after  abortion,  have  suffered  formerly  from  chronic  metritis  or  en- 
dometritis,  but  who  have  been  quite  free  from  any  symptoms  of 
these  troubles  for  many  years  prior  to  the  climacteric,  it  often  hap- 
pens that  the  change  of  life  is  ushered  in  by  symptoms  of  conges- 
tion of  the  uterus  with  associated  leucorrhoea.  With  the  completion 
of  the  menopause,  however,  the  resulting  involution  of  the  uterus 
exerts  a  favourable  influence  upon  all  such  chronic  inflammatory 
processes  in  the  genital  organs ;  as  the  atrophy  progresses,  the  peri- 
odic attacks  of  congestion  cease  to  recur.  Thus  it  happens  that 
women  who  for  years  have  suffered  from  haemorrhages,  from  in- 
flammatory disorders  of  the  genital  organs,  and  from  various  other 
troubles  of  a  similar  nature,  will,  once  the  menopause  is  fully  over, 
feel  quite  well  up  to  an  advanced  period  of  life  —  they  seem  as  it 
were  to  begin  life  afresh. 

According  to  Bennet,  the  characteristic  signs  of  climacteric  me- 
tritis are  that  the  inflammatory  symptoms  are  less'  pronounced,  that 
the  pains  are  less  severe,  that  elongation  of  the  cervix  is  less  often 
seen,  and  that  fungous  changes  are  less  marked,  than  is  the  case 
in  the  chronic  metritis  of  younger  women.  On  the  contrary,  the 
cervix  appears  smaller,  often  somewhat  lobulated,  it  is  harder, 
granulations  are  numerous,  ulceration  is  rare,  the  enlargement  of 
the  uterine  cavity  is  but  slight.  Bennet' s  views  are,  however,  opposed 
by  Scanzoiii,  who  maintains  that  there  is  no  notable  difference  be- 
tween the  chronic  metritis  of  younger  women  and  the  disease  as  it 
occurs  in  women  at  the  climacteric. 

In  fact,  the  chronic  metritis  and  endometritis  of  women  during 
the  climacteric  age,  differs  in  no  important  respect  from  these  dis- 
eases as  they  are  seen  in  women  during  their  sexual  prime.  We 


612  THE  SEXUAL  LIFE  OF  WOMAN. 

merely  note  that  the  enlargement  of  the  uterus  is  less  marked ;  but 
the  thickening  and  extreme  hyperaemia  of  the  mucous  membrane  are 
the  same  in  both  cases,  the  secretion  is  increased  in  quantity,  the 
vaginal  portion  of  the  cervix  is  elongated,  and  usually  displays  ero- 
sions, excoriations,  or  ulcers.  The  subjective  troubles  appear  less 
pronounced  than  in  the  case  of  the  metritis  of  the  menacme.  The 
prognosis  is  as  a  rule  a  more  favourable  one  than  in  the  earlier 
years  of  sexual  life,  for  as  soon  as  the  series  of  involuntary  proc- 
esses is.  completed,  when  the  retrogressive  changes  in  the  genital 
organs  are  at  an  end,  when  senile  atrophy  of  the  uterus  and  the 
uterine  annexa  has  set  in,  a  cure  of  the  troubles  formerly  so  obsti 
nate  and  so  enduring  speedily  takes  place. 

Quite  recently,  much  has  been  written  upon  the  subject  of  a 
peculiar  senile  endometritis  (Patru,  Skene,  Munde,  Ruder,  Sheldon, 
Herman,  and  others),  and  it  has  been  described  as  "  a  peculiar  form 
of  senile,  haemorrhagic,  leucocytal  hyperplasia  of  the  uterine  mucous 
membrane"  (Gottschalk}.  According  to  Mauraugc  and  Lorain  it 
occurs  in  as  many  as  7.2^  of  elderly  women.  It  is  seen  especially 
'n  women  who  earlier  in  life  have  suffered  from  diseases  of  the 
genital  organs,  more  especially  those  who  have  previously  suffered 
from  endometritis ;  at  times  a  senile  vulvitis  or  vaginitis  is  the  cause 
of  the  disease.  Displacements  of  the  uterus  with  kinking  of  its 
canal,  whereby  retention  of  the  secretion  and  its  decomposition  are 
induced,  has  been  assigned  as  an  additional  cause  of  the  disorder, 
also  prolapse  of  the  uterus,  and,  in  isolated  instances,  necrotic  fibro- 
mata. According  to  the  degree  to  which  the  atrophy  of  the  tissues 
has  proceeded,  and  according  as  the  mucous  membrane  is  still  partly 
retained  or  entirely  destroyed,  and  according  to  the  extent  to  which 
the  uterine  vessels  have  been  affected  with  the  sclerotic  processes 
of  old  age,  does  the  pathologico-anatomical  picture  of  senile  endo- 
metritis vary.  It  may  affect  the  body  only  of  the  uterus,  it  may  ex- 
tend also  to  the  cervix,  the  vagina,  and  even  the  vulva ;  upwards  it 
may  pass  to  the  uterine  annexa  and  to  the  peritoneum.  The  first 
and  most  important  symptom  of  this  senile  endometritis  is  the  out- 
flow, usually  intermittent,  rarely  continuous,  of  a  sero-purulent,  and 
sometimes  sanguineous  discharge,  with  a  powerful  foetid  smell; 
there  are  colicky  pains,  which  pass  off  when  the  uterus  has  emptied 
itself ;  often,  also,  there  are  atypical  bleedings,  which  are  not  profuse. 
The  uterus  is  usually  found  to  be  larger  than  the  atrophy  general  at 
the  patient's  age  would  have  led  us  to  expect,  it  is  often  retroflexed, 
the  cervix  is  thickened,  the  lips  of  the  os  uteri  are  usually  everted 
and  raw.  When  persistent,  this  senile  endometritis  causes  profound 
constitutional  disturbance,  and  is  often  difficult  to  differentiate  from 
carcinoma  of  the  uterus. 


SEXUAL  EPOCH  OF  THE  MENOPAUSE.  613 

Under  the  name  of  senile  irritation  of  the  uterus,  Maxwell  has 
described  a  disease  occurring  at  the  climacteric,  characterized  by  an 
enormously  increased  irritability  of  the  uterus,  with  marked  reflex 
manifestations ;  in  these  cases  also  we  may  perhaps  have  to  do  with  a 
senile  endometritis.  The  most  pronounced  symptom  is  a  severe  and 
constant  uterine  pain,  to  which  in  the  course  of  the  disease  are  super- 
added  pains  in  the  gastric  and  cardiac  regions,  the  rectum,  and  the 
spinal  column ;  these  pains  lasted  a  long  time,  and  their  severity  was 
such  that  it  became  necessary  in  some  cases  to  remove  the  uterus. 

Hydrometra  is  a  disease  which  makes  its  appearance  principally 
late  in  the  climacteric  period,  when  menstruation  has  already  com- 
pletely ceased,  and  when  the  adhesions  associated  with  the  climac- 
teric atrophy  of  the  uterus  have  led  to  atresia  of  the  cervical. canal. 
Among  74  cases  of  hydrometra  (from  the  material  of  the  Pathologi- 
co-Anatomical  Institute  of  Prague,  in  the  years  1868  to  1871)  not 
one  of  the  women  was  less  than  40  years  of  age ;  the  age  distribu- 
tion of  the  cases  was  in  fact  the  following : 

Quinquennium  40  to  45 3  cases 

Quinquennium  45  to  50 2  cases 

Quinquennium  50  to  55 2  cases 

Quinquennium  55  to  60 8  cases 

Quinquennium  60  to  65 18  cases 

Quinquennium  65  to  70 12  cases 

Quinquennium  70  to  75 II  cases 

Quinquennium  75  to  80 8  cases 

Quinquennium  80  to  85 4  cases 

Quinquennium  85  to  90 6  cases 

In  40  of  these  cases,  the  occlusion  was  in  the  region  of  the  os 
internum,  in  23  it  was  in  the  region  of  the  os  externum,  in  9  cases 
the  whole  length  of  the  cervical  canal  was  obliterated,  and  in  2  both 
the  internal  and  the  external  os  were  occluded,  the  intervening  por- 
tion of  the  cervical  canal  being  still  patent.  In  the  two  latter  cases, 
there  was  hydrometra  bicamerata,  with  retroflexion  of  the  uterus. 

Late  in  the  climacteric  period,  haematometra  also  occurs,  though 
less  often  than  hydrometra.  When,  in  cases  in  which  the  os  uteri 
externum  is  occluded,  in  consequence  of  adhesion  between  the 
vaginal  walls  and  the  vaginal  portion  of  the  cervix,  as  a  sequel  of 
the  vaginitis  ulcerosa  adhesiva  of  elderly  women,  there  is  haemor- 
rhage from  the  atheromatous  vessels  of  the  uterus  or  the  tubes, 
the  blood  necessarily  distends  the  uterine  cavity. 

During  the  climacteric  period,  leucorrhoea  is  so  extraordinarily 
frequent,  as  the  figures  previously  given  show,  that  the  assumption 
is  justified  that  with  the  diminution  or  cessation  of  the  menstrual 
flow,  this  hypersecretion  from  the  genital  mucous  membranes  forms 
as  it  were  a  kind  of  vicarious  flux.  Sometimes,  as  in  12  cases  re- 
corded by  Tilt,  we  actually  have  a  periodic  "  menstrual  leucorrhoea  " ; 


THE  SEXUAL  LIFE  OF  WOMAN. 

in  one  of  these  cases  the  discharge  recurred  at  regular  monthly  in- 
tervals for  12  months,  in  another  for  18  months,  in  several  for  2 
years,  and  in  one  for  as  long  as  7  years.  It  is  only  by  careful  exami- 
nation that  the  exact  source  of  the  discharge  can  be  determined,  for 
during  the  climacteric  also,  as  well  as  earlier  in  life,  leucorrhoea  may 
be  due  either  to  endometritis  or  to  colpitis.  A  muco-serous  or 
sanguino-serous  secretion  may  also  be  due  to  slight  vulvitis. 

A  peculiar  form  of  inflammation  occurring  after  the  completion 
of  the  menopause,  and  after  the  atrophic  process  in  the  vagina  is 
considerably  advanced,  is  known  as  colpitis  senilis.  In  this  disease, 
ulceration  readily  occurs,  followed  by  cicatricial  adhesion  between 
the  anterior  and  posterior  walls  of  the  vagina  (vaginitis  adhaesiva 
vetularum)  ;  in  other  cases  herpetiform  eruptions  arise,  with  a  ten- 
dency to  pustule  formation;  occlusion  of  the  vagina  may  lead  to 
hydrometra  and  pyometra ;  sometimes  the  obliteration  of  the  vagina 
is  complete,  so  that  there  is  neither  outlet  for  blood  from  the  uterus, 
nor  inlet  for  the  penis  during  coitus.  This  vaginitis  adhaesiva  vetu- 
larum is  by  no  means  rare  in  the  climacteric  period ;  as  a  rule  it 
does  not  give  rise  to  very  serious  trouble,  the  most  prominent  symp- 
tom being  usually  somewhat  persistent  haemorrhage,  unaccompanied 
by  any  evil  odour.  On  local  examination,  the  characteristic  strings 
of  scar  tissue  are  felt,  passing  from  the  portio  vaginalis  to  the 
narrowed,  senile  vaginal  fornix ;  from  the  cervical  canal  there  ex- 
udes a  usually  somewhat  vitreous  mucus,  mixed  with  blood.  The 
cervix  itself  is  thin  and  atrophied,  the  uterus  also  is  greatly  dimin- 
ished in  size. 

The  frequency  at  the  time  of  the  menopause  of  such  catarrhal 
inflammatory  processes  in  the  vagina  and  vulva  is  said  by  Dnpres  to 
depend  on  the  weakness  or  paresis  of  the  bladder  which  is  so  common 
in  women  at  this  time  of  life.  Owing  to  the  incomplete  evacuation 
of  the  urine,  cystitis  very  readily  ensues ;  the  urine  is  evacuated  in- 
voluntarily during  sleep,  and  some  of  this  fluid  passes  through  the 
vaginal  orifice,  giving  rise  all  the  more  readily  to  colpitis,  because 
the  secretion  of  the  atrophic  mucous  membrane  no  longer  possesses 
the  normal  acid  bactericidal  properties.  According  to  Scott,  vulvitis 
may  also  arise  as  a  sequel  of  calculus-formation  in  the  glands  of  Bar- 
tholin,  a  frequent  occurrence  in  elderly  life,  followed  by  inflamma- 
tion and  abscess-formation  in  these  glands.  Among  the  diseases  of 
the  genital  organs  at  the  climacteric  period,  Fritsch  also  enumerates 
urethral  caruncle  and  carcinoma  of  the  clitoris. 

Displacements  of  the  Uterus. — Among  the  commonest  of  the  dis- 
placements of  the  uterus  occurring  during  and  after  the  menopause, 
is  prolapse  of  the  organ.  Previously  existing  descent  of  the  uterus 
is  apt  to  be  greatly  aggravated  at  the  climacteric,  a  partial  prolapse, 


SEXUAL  EPOCH  OP  THE  MENOPAUSE.  615 

for  instance,  becoming  complete;  or  prolapse  of  the  uterus  may 
first  set  in  at  this  period  of  life. 

There  are  several  contributory  causes  of  the  liability  to  prolapse 
at  this  particular  epoch,  especially  in  women  who  have  had  a  great 
many  children,  and  in  those  with  either  enlargement  of  the  uterus 
or  with  lacerated  perineum ;  the  most  powerful  of  these  causes  being 
the  weakening  of  the  uterine  supports  in  consequence  of  the  general 
relaxation  of  the  pelvic  tissues.  At  the  menopause,  the  connective 
tissue  by  means  of  which  the  uterus  is  attached  to  surrounding 
structures,  withers ;  simultaneously  the  vagina  atrophies,  and  this 
source  of  support  is  weakened ;  the  whole  pelvic  floor  loses  its  firm- 
ness and  power  of  support.  For  these  reasons,  a  uterus  which  has 
hitherto  been  in  correct  position  readily  becomes  retroverted  and  to 
some  extent  prolapsed;  whilst  one  that  was  already  thus  far  dis- 
placed prior  to  the  menopause,  will  now  be  apt  to  descend  still 
further  till  it  rests  upon  the  perineum.  With  the  disappearance 
from  the  vulva  and  the  perineum  of  the  adipose  tissue  on  which 
their  firmness  so  largely  depends,  complete  prolapse  of  the  uterus 
is  now  likely  to  ensue.  Prolapse  of  the  urethra  may  also  result 
from  senile  involution  of  the  pelvic  contents. 

Among  my  500  cases  of  women  at  the  climacteric,  there  were  65 
instances  of  more  or  less  severe  prolapse  of  the  uterus.  The  fre- 
quency of  prolapse  in  women  at  the  climacteric  and  in  those  at  a 
more  advanced  age,  is  shown  by  the  following  figures,  which  are 
compiled  from  the  postmortem  statistics  of  the  Pathologico- 
Anatomical  Institute  of  Prague  (years  1868  to  1871).  Prolapse  of 
the  uterus  was  found: 

In  the  quinquennium  30  to  35  in 2  women 

In  the  quinquennium  35  to  40  in 2  women 

In  the  quinquennium  40  to  45  in 6  women 

In  the  quinquennium  45  to  50  in 3  women 

In  the  quinquennium  50  to  55  in 6  women 

In  the  quinquennium  55  to  60  in 8  women 

In  the  quinquennium  60  to  65  in 6  women 

In  the  quinquennium  65  to  70  in 4  women 

In  the  quinquennium  70  to  75  in 4  women 

In  the  quinquennium  75  to  80  in 4  women 

In  the  quinquennium  80  to  85  in 2  women 

Flexions  and  versions  of  the  uterus,  common  as  they  are  at  the 
time  of  the  menopause,  have  no  longer  the  same  importance  that 
they  possessed  during  the  prime  of  the  sexual  life.  For  on  the  one 
part  the  size  of  the  uterus  is  greatly  diminished,  in  consequence  of 
the  lessened  blood-supply  and  of  senile  involution  of  the  organ ;  and 
on  the  other,  after  the  cessation  of  menstruation,  the  profuse 
haemorrhages  and  severe  colicky  pains  which  for  the  most  part 
occurred  during  menstruation  in  these  cases  of  kinking  of  the 
uterine  canal,  and  which  gave  rise  to  such  severe  general  disturb- 


616  THE  SEXUAL  LIFE  OF  WOMAN. 

ance,  now  no  longer  occur.  Herein  lies  the  explanation  of  the  fact, 
well  known  to  all  experienced  practitioners,  that  women  who  have 
for  many  years  suffered  from  retroflexion  or  retroversion  of  the 
uterus  associated  with  severe  and  painful  symptoms,  cease  to  suffer 
after  the  menopause  is  established,  and  regain  excellent  health, 
although  the  local  condition  of  the  uterus  remains  unrelieved. 

Neoplasmata  of  the  Uterus  and  of  the  Uterine  Annexa. — 
The  most  serious  danger  to  the  life  of  a  woman  during  the  climac- 
teric period  is  to  be  found  in  the  strong  tendency  to  the  occurrence 
of  carcinomatous  disease  of  the  uterus  —  a  predisposition  so  marked 
that  not  less  than  one-half  of  all  illnesses  affecting  the  reproductive 
organs  of  women  at  this  age  are  cases  of  carcinoma  of  the  uterus. 
The  disease  occurs  especially  at  the.  beginning  of  the  climacteric, 
between  the  ages  of  45  and  50  years,  most  often  in  the  form  of 
carcinoma  of  the  portio  vaginalis,  whereas  after  the  completion  of 
the  menopause,  carcinoma  of  the  body  of  the  uterus  is  the  prepon- 
derant form.  The  true  reason  for  the  frequency  of  the  occurrence 
of  carcinoma  at  this  period  of  life  will  only  become  clear  to  us  when 
we  are  more  fully  acquainted  with  the  nature  and  origin  of  this  form 
of  malignant  disease.  Meanwhile,  it  would  seem  that  the  predis- 
position to  cancer  during  and  shortly  after  the  menopause  depends 
upon  the  anatomical  changes  in  the  reproductive  organs  at  the 
time  of  involution,  which  render  these  organs  a  more  suitable  soil 
for  the  proliferation  of  malignant  growths;  and  further  it  is 
probable  that  the  loss  of  the  acid,  bactericidal  quality  of  the  vaginal 
secretion,  opens  the  door  for  the  entrance  of  pathogenic  micro-or- 
ganisms. Noteworthy  is  the  observation  of  Baer  and  Leopold,  that 
very  frequently  a  preclimacteric  or  climacteric  fungous  endometritis 
forms  the  stage  of  transition  to  the  development  of  carcinoma  of  the 
body. of  the  uterus.  At  the  time  of  the  menopause  there  is  also 
an  increased  liability  to  the  occurrence  of  cancer  of  the  ovaries. 
Numerous  statistical  data  have  been  published  regarding  the  fre- 
quency with  which  carcinoma  of  the  uterus  occurs  at  various  periods 
in  women's  lives,  and,  notwithstanding  all  variations,  one  fact 
stands  out  clearly,  namely,  that  this  disease  occurs  most  frequently 
in  the  fourth  and  fifth  decennia,  and  above  all  during  the  climacteric 
period. 

From  Gusserow's  collection  of  526  cases,  observed  by  Lebert, 
Kiivisch,  Chiari,  Scanzoni,  and  Sacxingcr,  the  following  table  has 
been  drawn  up,  and  it  shows  very  clearly  the  great  preponderance  of 
the  disease  in  the  fifth  decennium  of  a  woman's  life: 

At  ages  of  from  20  to  30  there  were 12  cases 

At  ages  of  from  30  to  40  there  were '. 161  cases 

At  ages  of  from  40  to  50  there  were 217  cases 

At  ages  of  from  50  to  60  there  were 102  cases 

At  ages  of  from  60  to  70  there  were 38  cases 

At  ages  of  from  70  and  upwards  there  were 5  cases 


SEXUAL  EPOCH  OF  THE  MENOPAUSE.  617 

From  the  mortality  statistics  we  obtain  a  similar  result  as  regards 
the  age  incidence  of  carcinoma  of  the  uterus.  Thus,  in  England 
there  died  of  this  disease  in  one  year : 

Women  at  ages  of  from  15  to  25 44 

Women  at  ages  of  from  25  to  35 184 

Women  at  ages  of  from  35  to  45 717 

Women  at  ages  of  from  45  to  55 1 1 10 

Women  at  ages  of  from  55  to  65 1 1 16 

Women  at  ages  of  from  65  to  75 876 


Coming  now  to  the  consideration  of  fibromyomata  of  the  uterus, 
we  cannot  share  the  opinion  that  at  the  climacteric  age  there  is  a 
special  predisposition  to  the  origination  of  such  tumours,  or  that  the 
climax  favours  the  growth  of  already  existing  fibromyomata.  It 
appears  to  us  that  in  the  preclimacteric  epoch  and  the  commence- 
ment of  the  climacteric,  the  symptoms  of  existing  fibromyomata 
become  more  troublesome,  the  haemorrhages  are  more  severe,  the 
pains  more  violent;  but  that  as  the  menopause  is  established,  these 
troublesome  symptoms  decline  progressively  in  intensity,  and  not 
only  is  there  an  arrest  in  the  growth  of  the  tumours,  but  often  an 
actual  diminution  in  their  size. 

I  have  myself  repeatedly  observed  such  cases,  in  which  I  had  the 
opportunity  of  watching  the  growth  of  the  myomata  during  a  period 
of  ten  years  or  more.  Other  cases,  indeed,  show  that  myomata 
may  increase  in  size  after  the  menopause,  at  times  with  remarkable 
rapidity,  and  further  that  at  this  period  of  life  a  malignant  degen- 
eration may  occur  in  such  tumours.  Carcinomatous.,  sarcomatous, 
and  myxomatous  degeneration  have  been  observed,  and  also  the 
transformation  of  a  myoma  into  a  soft  fibrocystic  tumour. 

Atrophy  of  fibromyomatous  tumours  at  the  menopause,  associated 
with  the  atrophy  of  the  uterus  that  then  occurs,  has  been  observed 
by  Playfair  and  by  Doran.  The  tumour  shrinks,  its  muscle-cells 
become  smaller,  and  undergo  fatty  degeneration,  there  is  an  increase 
in  the  interstitial  connective  tissue,  so  that  ultimately  the  fibro- 
myoma  is  transformed  into  a  firm  and  dense  fibroid  swelling.  Cases 
in  the  older  literature  and  also  a  recent  observation  of  Yamagiron 
have  shown  that  calcification  of  uterine  fibromyomata  sometimes 
occurs,  leading  to  the  formation  of  the  so-called  "  uterine  calculi." 
In  the  case  of  pure  myomata,  the  diminution  in  size  occurring  at 
the  climacteric  is  generally  due  to  resorption  and  fatty  degeneration, 
whereas  in  the  case  of  fibromyoma  it  depends  on  induration  and 
atrophy.  It  remains  uncertain  whether  the  growth  of  purely  fibrous 
tumours  is  also  affected  by  the  climacteric. 

Whilst  the  influence  of  the  climacteric  en  the  growth  of  fibromy- 
omata is  thus  usually  advantageous  to  the  patient,  exceptions  occur, 


618  THE  SEXUAL  LIFE  OF  WOMAN. 

as  is  shown  by  cases  recorded  by  La-wson  Tait,  Schorler,  and  Boer- 
ner;  the  last-named  author  points  out  that  at  the  climacteric  there  is 
a  tendency  for  the  transformation  of  fibromyomata  into  sarcomata. 

Kleinwdchter  had  under  observation  78  cases  of  fibromyomata  of 
the  uterus  in  women  who  were  older  than  45  years;  in  only  8  of 
these  was  a  diminution  in  the  size  of  the  tumour  observed  at  the 
menopause;  in  II  cases  at  this  time,  the  tumour  increased  in  size 
more  or  less  rapidly ;  in  3  cases,  a  carcinomatous  change  occurred  in 
the  tumour ;  in  3  cases,  the  tumour  was  first  observed  at  the  time  of 
the  menopause;  in  13  cases,  the  haemorrhages  appeared  to  undergo 
a  complete  arrest  at  the  menopause,  but  the  size  of  the  tumour  was 
not  affected ;  in  the  remaining  48  cases,  no  influence,  either  favour- 
able or  unfavourable,  appeared  to  be  exercised  by  the  menopause  on 
the  fibromyoma  of  the  uterus. 

Cases  reported  by  Rogival,  Simpson,  and  Gusseroiv  indicate  the 
existence  of  a  certain  predisposition  to  the  growth  of  sarcomata  of 
the  uterus  at  the  climacteric  period.  Gusserow  more  particu- 
larly insists  on  the  fact  that  we  must  bear  in  mind  the  likelihood  of 
the  origination  of  a  fibrosarcoma  or  of  the  sarcomatous  transforma- 
tion of  a  fibromyoma,  in  all  cases  in  which  a  fibrous  tumour  of  the 
uterus  first  attracts  attention  at  the  climacteric  period ;  or  in  which 
a  tumour  hitherto  small  and  inconspicuous  and  giving  little  or  no 
trouble,  begins  at  this  time  to  increase  in  size  or  to  give  rise  to 
troublesome  symptoms. 

Neuroses  of  the  Reproductive  Organs. —  One  of  the  commonest 
neuroses  of  the  reproductive  organs  at  the  climacteric  period  is 
pruritus  vaginae  et  vulvae,  and  it  is  one  of  the  most  distressing 
symptoms  of  which  women  of  this  age  complain.  The  disorder  de- 
pends upon  a  hyperaesthesia  of  the  sensory  nerves  of  the  vagina 
and  the  external  organs  of  generation.  It  is  characterized  by  en- 
during sensations  of  itching  and  burning,  which  may  be  either 
periodic  (and  then  usually  nocturnal)  or  continuous;  at  times  it  be- 
comes so  severe  that  the  women  thus  affected  have  an  unceasing 
desire  to  scratch,  avoid  all  society,  and  ultimately  find  life  quite 
unbearable.  In  the  slighter  degrees  of  pruritus,  no  objective 
changes  are  to  be  observed  in  the  genital  organs,  or  at  most  some 
slight  hyperaemia  of  the  vaginal  orifice.  In  the  more  severe  forms, 
however,  there  are  local  nutritive  changes:  the  labia  are  swollen, 
their  surface  has  an  erythematous  blush,  a  number  of  the  hair-fol- 
licles are  enlarged  and  prominent ;  the  vaginal  orifice  is  abnormally 
sensitive,  it  is  scarlet  or  livid-red  in  colour  and  here  and  there  de- 
nuded of  epithelium,  and  there  are  scattered  mucous  follicles  dis- 
tended with  a  serous  or  purulent  fluid ;  these  small  vessels  are  to  be 
seen  chiefly  on  the  inner  surfaces  of  the  labia  minora  and  around 
the  clitoris.  At  the  same  time,  the  vulva  secretes  an  acid,  burning 


SEXUAL  EPOCH  OF  THE  MENOPAUSE.  619 

fluid,  which  greatly  increases  the  patent's  sufferings,  and  at  times 
impels  her  irresistibly  to  the  practice  of  masturbation.  In  cases  of 
long  standing,  we  find  hypertrophy,  elongation,  and  deformity  of 
the  nymphae,  and  pigmentation  of  these  organs,  with  the  formation 
of  varices. 

According  to  Fritsch,  in  exceptional  cases  pollutions  are  the 
originating  cause  of  the  pruritus,  and  this  may  be  the  case  in  women 
who  are  not  sexually  passionate.  It  occurs,  indeed,  especially  in 
matrons  who  have  not  had  sexual  intercourse  for  years,  and  who 
have  quite  ceased  to  think  about  sexual  matters;  during  the  night, 
such  a  woman  will  begin  to  have  voluptuous  dreams,  associated  with 
a  degree  of  sexual  stimulation  which  is  described  as  being  actually 
painful.  The  woman  often  suffers  greatly  from  these  lascivious 
sensations.  She  complains  that  she  cannot  understand  how  it  is 
that  she  has  become  affected  with  such  utterly  undesired  feelings. 
She  becomes  profoundly  depressed.  Coitus  often  gives  no  relief 
whatever;  but  many  women  thus  affected  declare,  as  Fritsch  points 
out,  that  by  powerful,  almost  involuntary  scratching,  the  stimulus 
is  speedily  subdued,  and  that  for  this'  reason  they  are  absolutely 
compelled  to  scratch.  It  will  readily  be  understood,  that  in  this  way 
persistent  pruritus  will  arise,  with  local  effects  of  scratching,  and 
vulval  eczema.  According  to  the  same  author,  in  some  instances 
pruritus  is  due  to  great  insufficiency  of  secretion,  such  as  occurs  in 
the  endometritis  atrophicans  which  he  was  the  first  to  describe. 
This  scanty  secretion,  as  it  passes  over  the  external  genital  organs, 
gives  rise  to  irritation  and  itching.  Haemorrhoids  also  play  a  part 
in  the  etiology  of  pruritus. 

Diseases  of  the  Mammae. —  The  sympathy  which  in  the  earlier 
phases  of  the  sexual  life — during  the  menarche,  during  pregnancy, 
and  during  the  puerperium — so  obviously  exists  between  the 
breasts  and  the  uterus,  is  seen  also  during  the  climacteric  period.  It 
now  finds  expression  chiefly  in  the  marked  tendency  to  new  growths 
in  the  mammae,  a  matter  to  which  attention  was  already  drawn  by 
Galen.  The  commonest  of  these  neoplasmata  is  carcinoma  mammae, 
a  disease  which  occurs  chiefly  during  the  climacteric  epoch.  In  the 
great  majority  of  cases,  cancer  of  the  breast  is  a  primary  disorder; 
in  exceptional  cases,  however,  the  carcinoma  of  the  breast  arises  by 
metastasis  from  a  cancer  of  the  uterus  or  the  ovary.  Sometimes 
the  breast  tumour  is  preceded  by  Paget's  disease  of  the  nipple.  For 
several  years  the  patient  suffers  from  what  appears  to  be  a  chronic 
dermatitis  of  the  nipple,  the  areola  mammae,  and  the  surrounding 
skin;  but  ultimately,  and  hardly  ever  before  the  commencement  of 
the  menopause,  carcinoma  of  the  breast  ensues. 

The  older  statistical  enquiries  of  Birkett,  Lebert,  Scanzoni,  and 
Vclpeau,  showed  that  carcinoma  mammae  most  commonly  occurred 


620  THE  SEXUAL  LIFE  OF  WOMAK. 

between  the  ages  of  40  and  50  years,  and  next  to  that  in  frequency 
between  the  ages  of  50  and  60  years. 

A  general  hypertrophy  of  the  mammary  gland,  affecting  not  only 
the  enveloping  and  intra-lobular  adipose  and  connective  tissue,  but 
also  the  proper  glandular  substance,  is  very  rarely  observed  during 
the  climacteric  period ;  but  in  the  preclimacteric  epoch  and  in  the 
early  part  of  the  climacteric,  we  not  uncommonly  see  a  hyperplasia 
of  the  adipose  tissue  of  the  breast,  either  as  a  local  manifestation  of 
a  developing  general  obesity,  lipomatosis  universalis,  or  as  a  purely 
local  excessive  deposit  of  fat.  In  such  circumstances,  the  mammae 
may  at  times  be  transformed  into  monstrous  tumours. 

Diseases  of  the  Organs  of  Circulation. 

Among  the  cardiac  disorders  of  the  menopause,  the  earliest  and 
the  commonest  is,  in  my  own  experience,  the  following.  At  the 
time  of  the  menopause,  exceptionally  not  till  after  the  complete  ces- 
sation of  menstruation,  but  usually  at  the  commencement  of  this 
period  of  life,  some  time,  that  is  to  say,  between  the  age  of  40  and 
50,  either  when  menstruation  has  become  irregular,  the  intermen- 
strual  interval  having  become  longer  or  shorter  than  has  hitherto 
been  the  case,  or  when  the  discharge  has  become  abnormal  in  char- 
acter, a  woman  who  has  not  before  suffered  from  any  kind  of 
cardiac  disorder,  will  begin  to  complain  of  paroxysms  of  palpitation. 

In  some  cases  the  attacks  of  palpitation  occur  in  the  absence  of  any 
discoverable  exciting  cause;  in  others,  some  trifling  stimulus  gives 
rise  to  them.  They  may  arise  when  the  patient  is  in  any  position, 
walking,  standing,  sitting,  or  recumbent;  sometimes  even  during 
sleep.  The  subjective  sensation  aroused  by  the  increased  force  and 
frequency  of  the  cardiac  action  is  described  as  extremely  dis- 
tressing; it  is  associated  with  a  feeling  of  anxiety  (Angst),  with  a 
sense  of  pressure  in  the  chest,  with  forcible  pulsation  of  the  carotids 
and  of  the  abdominal  aorta;  frequently  also  with  a  feeling  of  a 
rush  of  blood  to  the  head,  with  fugitive  heats,  and  severe  headache ; 
sometimes  towards  the  end  of  the  attack  there  is  a  sense  of  flicker- 
ing before  the  eyes  (as  of  muscae  volitantes),  tinnitus  aurium, 
dizziness,  and  in  rare  cases  actual  syncope. 

Objectively,  during  the  paroxysm,  a  notable  increase  in  the  fre- 
quency of  the  heart's  action  can  be  detected,  the  pulse-rate  rising  to 
120  or  even  150  per  minute.  In  most  of  my  cases,  the  pulse 
throughout  the  attack  remained  strong,  well-filled,  and  regular. 
Sphygmographic  tracings  taken  during  the  seizures  showed  a  remark- 
ably high  pulse-wave,  the  ascending  limb  of  the  curve  rose  rapidly 
and  suddenly,  the  descending  limb  fell  with  corresponding  steepness 
and  rapidity,  and  it  reached  an  unusually  low  level  before  the  com- 


SEXUAL  EPOCH  OF  THE  MENOPAUSE.  621 

mencement  of  the  dicrotic  elevation,  which  latter  was  exceptionally 
large ;  the  predicrotic  elevations,  on  the  other  hand,  were  but  slightly 
developed.  On  auscultation,  the  tones  of  the  heart  were  pure,  but 
were  louder  than  normal. 

Sometimes  during  a  paroxysm  a  sudden  reddening  of  the  face 
was  noticeable,  extending  often  to  the  neck  and  the  thorax.  In  the 
areas  mentioned,  vivid  red  patches  would  suddenly  make  their  ap- 
pearance, disappearing  more  gradually  after  lasting  a  few  minutes 
—  this  appearance  was  associated  with  a  burning  sensation  of  the 
affected  areas.  In  some  cases  during  the  paroxysm  there  was  an 
outbreak  of  perspiration  on  the  head  and  the  back. 

Associated  with  these  cardiac  troubles  of  women  at  the  climacteric 
we  usually  find  a  state  of  physical  and  mental  disquiet ;  less  common 
associations  are,  an  incapacity  for  regular  work,  sleep  uneasy  and 
much  disturbed  by  dreams,  great  general  nervous  irritability,  or 
signs  of  passive  congestion  in  various  organs;  occasionally  there  is 
oedema  of  the  lower  extremities;  the  urine  remains  free  from 
albumen. 

In  most  of  the  cases  of  this  nature  which  came  under  my  own 
observation,  a  certain  plethora  was  noticeable ;  among  women  at 
the  menopause,  it  was  especially  the  well-nourished,  powerful, 
sanguine  individuals,  that  were  liable  to  palpitation  of  the  heart. 
Direct  examination  of  the  blood  sometimes  showed  a  very  high 
haemoglobin  richness —  no,  115,  or  even  120,  as  compared  with  a 
haemoglobin-richness  of  93  in  normal  woman.  Several  of  my 
patients  presented  the  clinical  "picture  of  the  plethoric  form  of 
lipomatosis  universalis. 

In  all,  during  ten  years,  I  observed  67  cases  of  paroxysmal 
tachycardia  in  climacteric  women.  The  age  distribution  was  the 
following: 

,36  years  of  age I  woman 

38  years  of  age I  woman 

39  years  of  age 2  women 

40  to  45  years  of  age 37  women 

45  to  50  years  of  age 28  women 

Over  50  years  of  age 8  women 

Five  of  the  patients  were  unmarried,  three  were  married  but 
childless,  the  remaining  59  were  parous  women. 

As  a  general  rule,  women  live  in  great  dread  of  all  manifesta- 
tions of  bodily  disorder  during  the  menopause;  those  who  become 
affected  with  paroxysmal  tachycardia  are  exceptionally  anxious,  and 
regard  themselves  as  threatened  by  a  "  stroke."  This  pessimistic 
view  is  however,  by  no  means  justified.  These  cardiac  disorders 
may  make  their  appearance  some  time  before  the  menopause,  they 
may  persist  throughout  the  period  during  which  menstruation  is 


622  THE  SEXUAL  LIFE  OF  WOMAN. 

irregular,  they  may  even  endure  for  some  time  after  the  total  cessa- 
tion of  the  flow  —  but  serious  consequences  of  this  climacteric 
tachycardia  have  never  come  under  my  observation.  As  regards 
treatment  of  the  disorder,  I  have  seen  very  favourable  results  from 
the  following  measures :  The  systematic  employment  of  mild  pur- 
gatives, combined  with  suitable  dietetic  and  hygienic  regulations 
(bland  diet,  regular  and  strenuous  exercise,  cold  ablutions,  and  wet 
compresses  surrounding  the  abdomen). 

When  we  enquire  regarding  the  cause  of  the  tachycardiac 
paroxysms  occurring  at  the  menopause,  we  must  first  of  all  bear  in 
mind  that  in  the  cases  which  have  come  under  my  own  observation, 
the  cardiac  impulse  was  powerful,  the  pulse  strong  and  well-filled, 
that  signs  of  general  vaso-motor  disturbance  (ardor  fugax,  etc.) 
accompanied  the  tachycardiac  seizures, —  hence  we  are  led  to  infer 
that  we  have  to  do  with  a  stimulation  of  the  excito-motor  nerve 
fibres,  which  would  appear  to  be  due  to  the  climacteric  changes 
previously  described  as  occurring  in  the  female  reproductive  organs. 
This  view  receives  support  from  the  fact  that  after  oophorectomy, 
when,  as  in  the  normal  climacteric,  atrophic  processes  occur  in  the 
internal  reproductive  organs,  paroxysms  of  nervous  palpitation  are 
frequently  observed.  The  same  explanation  applies  to  the  fact  that 
in  women  at  the  climacteric  affected  with  these  tachycardiac 
troubles,  we  frequently  see  in  association  therewith  the  symptoms  of 
uterine  dyspepsia. 

But  in  addition  to  these  local  anatomical  changes  in  the  repro- 
ductive organs,  to  which  an  etiological  role  must  be  assigned  in  the 
production  of  climacteric  tachycardia,  the  irritable  state  of  the  ac- 
celerator nerves  must  also  depend  in  part  upon  that  general  nervous 
hyperexcitability  which  is  so  often  a  characteristic  feature  of  the 
climacteric  period  in  women,  manifesting  itself  in  manifold  hyper- 
aesthesias,  hyperkinesias,  neuralgias,  and,  in  extreme  cases,  mental 
aberration.  The  sensory  nerves  are  more  irritable  than  in  their 
normal  state,  so  that  every  stimulus  acting  upon  them  evokes  a 
greater  central  effert  than  heretofore,  and  upon  this  ensues  an  exag- 
geration of  various  reflex  manifestations,  which  appear  altogether 
disproportionate  to  the  strength  of  the  exciting  cause ;  among  these 
disproportionate  reflex  effects,  is  to  be  numbered  the  tachycardia 
just  described. 

But  in  addition  to  the  causes  of  climacteric  tachycardia  already 
enumerated,  we  have  to  take  into  consideration  the  results  of  recent 
investigations  concerning  the  organo-therapeutic  employment  of 
the  chemical  constituents  of  the  ovarian  tissue;  it  would  seem  that 
when  at  the  menopause  the  ovaries  undergo  atrophy,  so  that  their 
internal  secretion  is  no  longer  poured  into  the  blood,  the  resulting 


SEXUAL  EPOCH  OF  THE  MENOPAUSE.  623 

alteration  in  the  chemical  constitution  of  that  fluid  gives  rise  to  a 
"disturbance  of  the  vasomotor  centre  in  the  medulla  oblongata. 

In  some  cases,  the  tachycardiac  paroxysms  appear  to  be  connected 
with  the  erotic  excitement  to  which  women  are  sometimes  subject 
at  the  climacteric,  voluptuous  crises  and  ejaculation  occurring;  it  is 
possible  that  in  some  of  these  cases  masturbation  plays  a  part. 

A  second  group  of  cardiac  troubles  occurring  in  climacteric 
women  consists  of  cases  which  are  very  common,  but  not  often  very 
severe.  The  cases  in  question  depend  upon  the  liability  to  an  in- 
creased deposit  of  adipose  tissue  in  the  body  at  the  time  of  the  meno- 
pause, and  in  this  connexion  the  plethoric  form  of  lipomatosis  uni- 
versalis  almost  invariably  predominates.  It  is  a  well-known  fact 
that  between  the  ages  of  40  and  50  years  women  have  an  excessive 
tendency  to  obesity,  and  that  even  those  women  who  have  hitherto 
been  extremely  lean  are  apt  to  become  quite  plump  at  the  climacteric 
period.  Chiefly  in  consequence  of  this  increasing  obesity,  there 
occurs  in  climacteric  women  a  series  of  cardiac  troubles  of  very 
variable  intensity.  If  the  deposit  of  fat  is  effected  very  gradually, 
and  if  the  obesity  does  not  become  extreme,  it  is  only  after  vigorous 
bodily  exercise,  such  as  fast  walking  or  going  upstairs,  and  after 
meals,  that  the  patient  is  troubled  with  a  little  shortness  of  breath 
and  moderate  palpitation ;  appetite,  digestion,  and  sleep  remain 
usually  unaffected  in  cases  of  this  degree  of  severity.  Definite  at- 
tacks of  cardiac  asthma,  and  well-marked  signs  of  cardiac  insuffi- 
ciency affecting  the  entire  circulatory  system,  will  very  rarely  occur 
in  such  persons. 

It  is  an  interesting  fact,  that  the  troubles  which  arise  from  fatty 
deposits  around  the  heart  are  in  general  far  less  severe  in  climacteric 
women  than  they  are  in  obese  men  of  corresponding  age.  This 
may  be  due  to  the  circumstance  discovered  by  W.  Midler,  in  the 
course  of  his  investigations  on  the  proportions  of  the  human  heart, 
that  in  the  development  of  general  obesity,  the  pericardial  fat  in- 
creases proportionately  to  a  greater  extent  in  the  male  than  in 
female.  But  in  my  opinion  the  true  explanation  is  to  be  found  in 
the  fact  that  variations  in  the  amount  of  fat  in  the  body  are  normally 
far  more  extensive  in  women  than  in  men ;  at  puberty,  during  preg- 
nancy, and  during  lactation,  extensive  though  gradually  effected 
changes  in  the  amount  of  adipose  tissue  in  various  parts  of  the  body 
occur,  so  that  experience  has  rendered  the  organism  ready  to  adapt 
itself  to  the  further  changes  that  take  place  at  the  climacteric  — 
above  all,  the  heart  has  become  competent  to  meet  very  various  de- 
mands upon  its  powers. 

Only  in  women  who  from  youth  onwards  have  exhibited  a  marked 
tendency  to  obesity,  and  in  whom  at  the  climacteric  age  such  obesity 


624  THE  SEXUAL  LIFE  OF  WOMAN. 

has  b.ecome  extreme,  do  the  cardiac  troubles  attendant  on  the  meno- 
pause become  very  severe.  In  such  persons,  palpitation  and  short^ 
ness  of  breath  occur  on  slight  exertion,  and  attacks  of  cardiac 
asthma  are  frequent.  In  consequence  of  the  diminished  propulsive 
power  of  the  heart,  circulatory  difficulties  make  their  appearance  in 
the  most  widely  divergent  venous  areas ;  the  forms  most  commonly 
met  with  are,  varices  in  the  veins  of  the  lower  extremities,  perma- 
nent dilatation  of  certain  of  the  small  superficial  veins  of  the  skin, 
phlebectases  of  the  rectal  veins  (i.  e.  "piles"),  and  ultimately  we 
see  the  well-known  series  of  symptoms  of  venous  engorgement  — 
oedema  of  the  feet,  passive  congestion  of  the  lungs,  albumen  in  the 
urine,  etc. 

When  such  cardiac  troubles  are  present,  the  objective  examination 
of  the  heart  shows  in  the  early  stage  no  gross  abnormality ;  at  most 
the  heart-tones  seem  somewhat  weakened,  with  a  moderate  enlarge- 
ment of  the  area  of  percussion-dulness,  whilst  the  impulse  is  dis- 
placed a  little  outwards,  and  is  weaker  than  normal.  In  some  cases, 
however,  a  marked  dulness  on  percussion  over  the  sternum  indicates 
an  extensive  deposit  of  fat  in  the  mediastinal  tissues.  In  the  second 
stage  of  the  fatty  heart,  when  the  symptoms  have  become  more 
severe,  wre  find  a  considerable  enlargement  of  the  area  of  cardiac 
dulness  both  in  the  vertical  and  the  horizontal  extent;  the  cardiac 
impulse  is  diffused  as  well  as  feeble.  The  sounds  of  the  heart  are 
usually  pure  but  faint  —  in  some  cases  they  remain  loud  and  clear. 
Exceptionally,  a  short  blowing  murmur  is  heard  with  the  first 
sound ;  and  sometimes  this  sound  is  reduplicated. 

Whilst  in  the  first  stage  the  pulse  is  hardly  abnormal,  in  the  second 
stage,  very  various  changes  occur ;  often  it  is  subdicrotic  or  dicrotic 
in  character. 

In  the  great  majority  of  instances,  in  these  cases  of  cardiac  dis- 
order at  the  menopause,  provided  a  suitable  dietetic  regimen  is  early 
adopted  and  perseveringly  carried  out,  we  may  give  a  hopeful  prog- 
nosis. 

A  third,  less  common  but  far  more  serious  form  of  cardiac  dis- 
order occurring  at  the  menopause,  displays  the  well-known  symp- 
toms of  cardiac  failure.  Those  thus  affected  are  usually  slightly 
built,  delicate  women,  who  during  the  years  of  development  suffered 
from  chlorosis,  who  in  adult  life  were  troubled  with  anaemic  symp- 
toms, and  in  whom  the  menopause  was  ushered  in  by  very  severe 
losses  of  blood ;  sometimes,  again,  they  are  women  who  throughout 
their  sexual  prime  have  been  accustomed  to  menstruate  very  abun- 
dantly, who  have  had  numerous  and  severe  deliveries,  or  who  have 
had  frequent  miscarriages  —  it  is  in  those  who  have  thus  been 
weakened  by  frequent  and  profuse  haemorrhages,  that  the  symptoms 
of  cardiac  failure  ensue  at  the  climacteric  period.  The  women  thus 


SEXUAL  EPOCH  OF  THE  MENOPAUSE.  625 

affected  also  frequently  suffer  from  palpitation  of  the  heart;  the 
pulse  is  abnormally  frequent,  small,  low,  and  easily  compressible, 
and  sometimes  intermittent  or  arrhythmical.  The  heart's  action  is 
weak  and  devoid  of  energy.  The  heart-sounds  are  usually  obscure, 
and  sometimes  a  systolic  murmur  is  audible.  The  patients  are  short 
of  breath  and  are  subject  to  attacks  of  cardiac  asthma,  not  infre- 
quently associated  with  angina  pectoris.  In  conjunction  with  these 
symptoms,  we  see  signs  of  venous  congestion :  sudden  attacks  of 
coldness  in  the  hands  and  feet,  often  also  oedema  of  the  feet ;  the 
urine  at  times  contains  albumen.  The  haemoglobin-richness  of  the 
blood  is  always  notably  diminished.  I  need  not  discuss  in  further 
detail  the  well-known  symptoms  of  cardiac  insufficiency,  and  I  need 
only  insist  that  when  these  symptoms  are  met  with  in  women  at  the 
climacteric,  it  is  of  the  greatest  importance,  alike  from  the  pro- 
gnostic and  from  the  therapeutic  standpoint,  to  make  a  careful  ex- 
amination of  the  reproductive  organs,  so  as  to  determine  the  exact 
source  of  the  recurrent  bleedings  which  usually  constitute  the 
primary  cause  of  the  patient's  sufferings. 

In  several  cases  of  this  kind,  I  found  that  the  haemorrhages  were 
due  to  a  relaxation  of  the  uterine  tissues,  and  that  this  relaxation 
was  itself  referable  to  intrapelvic  circulatory  disturbances,  depend- 
ent upon  obstruction  in  the  vena  cava  inferior,  whereby  the  venous 
return  from  the  pelvis  was  rendered  difficult,  and  an  engorgement 
of  the  uterine  vessels  was  brought  about. 

In  some  instances  of  cardiac  failure  at  the  menopause,  chronic 
inflammation  within  the  pelvis  is  to  blame  for  the  menorrhagia  upon 
which  the  cardiac  failure  depends.  Often,  again,  the  haemorrhages 
are  referable  to  vasomotor  influences,  such  as  are  liable  during  the 
menopause  to  affect  various  vascular  areas.  In  other  cases,  the 
recurrent  bleeding  is  due  to  retroflexion  of  the  uterus,  to  prolapse 
of  that  organ,  or  to  tumour,  it  may  be  myoma,  polypus,  or  carci- 
noma. 

Finally,  during  the  menopause,  more  especially  in  women  in  whonj 
menstruation  has  continued  up  to  or  beyond  the  fiftieth  year,  or  in 
those  who  have  given  birth  to  a  large  number  of  children  or  have 
lived  lives  of  severe  bodily  exertion,  cardiac  troubles  may  arise  de- 
pendent upon  arterio-sclerosis  of  the  great  vessels.  The  signs  of 
such  changes  in  the  walls  of  the  bloodvessels  are  clearly  marked : 
the  cardiac  impulse  is  heaving,  the  second  sound  of  the  heart  is 
accentuated ;  the  pulse  is  full  and  large,  usually  giving  a  very 
powerful  blow  to  the  examining  finger,  whilst  its  sphygmographic 
tracing  exhibits  characteristic  signs  in  the  exceptional  height  and 
great  distinctness  of  the  first  predicrotic  elevation.  The  subjective 
troubles  are  in  these  cases  very  severe;  dyspnoea  and  attacks  of 
40 


626  THE  SEXUAL  LIFE  OF  WOMAN. 

asthma  or  of  vertigo  are  common,  and  sometimes  albumen  may  be 
found  in  the  urine. 

.  We  may  thus  summarize  the  cardiac  disorders  met  with  at  the 
menopause,  and  more  or  less  directly  dependent  upon  the  changes 
undergone  by  the  feminine  organism  at  that  period  of  life : 

1.  Paroxysmal  tachycardia,  a  reflex  neurosis  due  to  the  climac- 
teric changes  in  the  ovaries. 

2.  Nervous  palpitation  in  women  who  were  similarly  affected  at 
the  time  of  the  menarche,  and  in  whom  the  trouble  is  merely  the 
expression  of  a  very  unstable  nervous  system,  and  one  influenced  with 
especial  readiness  by  impressions  proceeding  from  the  reproductive 
organs. 

3.  Cardiac  disorder  due 'to  the  obesity  so  commonly  occurring  as 
a  part  of  the  general  metabolic  changes  of  the  menopause,  but  more 
particularly  dependent  upon  a  deposit  of  fat  in  the  neighbourhood 
of  the  heart  itself. 

4.  Symptoms  of  cardiac  failure,  due  to  excessive  losses  of  blood 
at  the  menopause,  either  as  an  exaggeration  at  this  time  of  men- 
strual processes,  or  as  a  result  of  some  actual  disease  within  the 
pelvis. 

5.  Cardiac  disorder  in  women  in  whom  the  menopause  occurs  at 
an  unusually  advanced  age,  and  dependent  upon  arteriosclerosis. 

Particular  consideration  must  be  given  to  a  symptom  not  infre- 
quently occurring  in  association  with  the  cardiac  troubles  of  cli- 
macteric women,  and  referable  to  the  circulatory  disturbances  char- 
acteristic of  this  period  of  life,  namely,  vertigo.  The  attack  in  some 
cases  comes  on  without  apparent  cause,  in  others  it  occurs  on  the 
performance  of  some  unusual  movement  or  the  adoption  of  some 
peculiar  posture  (stooping,  or  the  like)  ;  the  patient  is  suddenly 
seized  with  a  sense  of  rotation,  either  of  his  own  body,  or  else  of  his 
visible  and  palpable  environment ;  with  this  is  associated  a  sensation 
of  disturbance  of  equilibrium,  flickering  before  the  eyes  (muscae 
•volitantes),  tinnitus  annum,  palpitation  of  the  heart,  increased  fre- 
quency of  the  pulse,  which  may  be  either  full  or  small,  redness  or 
pallor  of  the  face,  coldness  of  the  hands  and  feet,  muscular  twitch- 
ings,  a  sense  of  great  anxiety,  and  the  outbreak  of  a  cold  perspira- 
tion. The  vertigo  occurs  in  paroxysms,  usually  of  short  duration  — 
a  few  minutes  to  a  quarter  of  an  hour.  It  is  especially  plethoric 
and  obese  women  who  are  liable  at  the  climacteric  to  suffer  from 
this  disorder. 

A  somewhat  similar  condition  is  described  by  Tilt  under  the  name 
of  "  pseudo-narcotism,"  as  frequently  occurring  in  climacteric 
women.  Tilt  indeed  states  that  in  500  such  women,  he  noted  its 
presence  in  no  less  than  277. 


SEXUAL  EPOCH  OF  THE  MENOPAUSE.  627 

Many  hypotheses  have  been  promulgated  to  account  for  the  ver- 
tigo that  so  frequently  occurs  at  the  menopause.  Both  anaemia  and 
hyperaemia  of  the  brain  have  been  assumed  as  causes,  alike  depend- 
ent upon  the  irregularity  of  menstruation,  which  is  supposed  to  have 
a  reflex  influence  upon  the  cerebral  circulation.  Others  regard  the 
vertigo  as  a  climacteric  neurosis,  since  it  occasionally  occurs  before 
the  menstrual  irregularities  begin,  and  in  such  cases  a  reflex  dis- 
turbance of  the  cerebral  circulation  cannot  be  supposed  to  have 
arisen.  According  to  Maiusch,  climacteric  vertigo  is  a  manifesta- 
tion of  epilepsy  —  an  explanation  which  has  been  often  extended  to 
include  all  the  menstrual  psychoses.  Windscheid  believes  that  in 
many  of  the  cases  the  vertigo  is  to  be  explained  by  the  existence  of 
arteriosclerotic  changes  in  the  blood  vessels,  such  as  are  already  by 
no  means  rare  at  the  age  at  which  the  menopause  usually  occurs ; 
whilst  in  other  cases,  he  believes,  the  vertigo  is  to  be  regarded  as 
one  of  the  symptoms  of  a  nervous  disorder.  That  in  any  case  the 
vertigo  is  dependent  in  some  way  upon  the  changes  that  occur  in  the 
reproductive  organs  at  the  climacteric  period,  is  shown  by  the  fact 
that  after  the  final  cessation  of  menstrual  activity  the  patient  as  a 
rule  ceases  to  suffer  from  this  symptom. 

To  the  circulatory  disturbances  consequent  upon  the  menopause 
we  must  also  refer  ardor  fugax,  fugitive  heat,  the  sudden  rushes  of 
blood  to  which  women  are  prone  at  this  period  of  life. 

The  cardiac  troubles  of  the  menopause  are  seen  especially  in 
women  in  whom  the  cessation  of  menstruation  occurs  quite  suddenly, 
and  in  those  in  whom  menstrual  activity  ceases  at  an  exceptionally 
early  age.  It  would  seem  that  in  such  cases,  owing  to  the  continu- 
ance of  periodic  maturation  of  the  graafian  follicles  associated  with 
congestion  of  the  intra-pelvic  organs,  in  the  absence  of  the  periodic 
relief  to  that  congestion  afforded  by  the  menstrual  flux,  there  re- 
sults a  summation  of  stimuli,  whereby  the  accelerator  nerves  of  the 
heart  are  very  powerfully  affected. 

Thus,  I  had  under  my  care  a  lady  from  Smyrna  36  years  of  age. 
She  had  begun  to  menstruate  when  12  years  of  age  and  menstru- 
ation was  always  scanty;  she  married  when  15  years  old,  and  finally 
ceased  to  menstruate  when  19  years  of  age ;  she  was  sterile,  and  no 
abnormality  could  be  detected  on  physical  examination  of  her  re- 
productive organs.  Every  month  she  suffered  from  severe  paroxys- 
mal tachycardia,  with  dyspnoea,  rush  of  blood  to  the  head,  perspira- 
tion of  the  face,  etc. 

In  another  case,  that  of  a  woman  45  years  of  age,  menstruation, 
hitherto  regular,  was  suddenly  suppressed,  during  the  flow,  in  con- 
sequence of  a  severe  fright.  The  next  month  the  flow  failed  to 
appear  at  the  usual  time,  but  instead  the  patient  was  affected  with 
severe  cardiac  distress,  accompanied  by  sudden  sensations  of  heat 


628  THE  SEXUAL  LIFE  OF  WOMAN. 

in  the  face,  palpitation  of  the  heart,  and  vertigo ;  these  symptoms 
lasted  for  several  days,  and  since  then  have  recurred  at  intervals  of 
three  or  four  weeks. 

The  cardiac  troubles  of  the  menopause  are  seen  with  especial  fre- 
quency in  women  who  were  affected  with  similar  disturbancs  at  the 
time  of  the  menarche.  Experience  clearly  shows  that  a  certain 
connexion  exists  between  the  manifestations  that  accompany  the 
commencement  of  sexual  activity,  and  those  that  accompany  the 
decline  and  extinction  of  that  activity;  and  a  physician  will  rarely 
be  mistaken  if  he  bases  on  the  fact  that  the  general  health  was  or 
was  not  seriously  affected  at  the  age  of  puberty,  a  prognosis  that  the 
course  of  the  climacteric  will  be  an  unfavourable  or  a  favourable  one, 
respectively.  In  other  words,  in  women  whose  nervous  system  is 
an  unstable  one,  and  in  those  with  hereditary  predisposition  to  the 
occurrence  of  cardiac  disorder,  the  changes  that  take  place  in  the 
reproductive  organs  both  during  the  menarche  and  during  the  meno- 
pause, are  likely  during  these  vital  phases  to  arouse  reflex  disturb- 
ances of  the  cardiac  functions.  The  facts  thus  noted  are  analogous 
to  those  observed  by  Potaln,  who  distinguishes  a  peculiar  form  of 
chlorosis,  occurring  in  delicate  individuals  at  the  age  of  puberty, 
and,  though  apparently  cured  during  the  menacme,  recurring  in  its 
primitive  severity  at  the  time  of  the  menopause. 

Again,  women  with  a  sanguine  and  erethistic  temperament  are 
more  inclined  to  suffer  from  cardiac  troubles  at  the  menopause  than 
women  of  a  tranquil  temperament  and  those  endowed  with  an 
unimpressionable  nervous  system. 

Finally,  elderly  virgins,  women  who  have  for  many  years  lived 
in  chaste  widowhood,  sterile  women,  women  who  have  married 
shortly  before  the  menopause,  or  who  at  this  time  have  recently 
been  delivered,  are  all  more  inclined  to  the  cardiac  troubles  of  the 
climacteric  period  than  women  whose  sexual  life  has  been  of  a  less 
abnormal  character. 

In  the  literature  of  the  subject,  we  find  numerous  references  to 
the  fact  that  among  the  disorders  of  the  climacteric,  circulatory  dis- 
turbances play  a  part.  But  a  full  and  accurate  account  of  these 
disorders  is  lacking  alike  in  the  literature  of  gynecology  and  in  that 
relating  to  diseases  of  the  heart  —  and  this  is  true  even  of  the  most 
recent  publications. 

Among  striking  individual  cases,  one  recorded  by  Moon  may  be 
mentioned  here,  a  case  of  tachycardia  consequent  upon  a  sudden 
menopause :  "  In  a  woman  35  years  of  age  the  menses  were  sup- 
pressed owing  to  chill ;  the  pulse-frequency  increased  from  80  to  200, 
without  any  apparent  change  in  the  heart  or  its  valves ;  the  symp- 
tom lasted  for  several  days,  when  menstruation  became  once  more 
established,  and  the  pulse-frequency  fell  again  to  the  normal, 


SEXUAL  EPOCH  OF  THE  MENOPAUSE.  629 

Tilt  expresses  the  opinion  that  the  heart  is  but  little  involved  in 
the  disturbances  of  the  climacteric,  his  experience  coinciding  with 
that  of  Quain.  Bocrner  and  Glacvecke,  on  the  contrary,  describe 
the  heart  troubles  of  the  climacteric  in  terms  very  similar  to  those 
employed  -by  myself. 

A.  Clement  describes  a  peculiar  form  of  disturbance  of  the  func- 
tions of  the  heart  at  the  climacteric  period,  to  which  he  gives  the 
name  of  Cardiopathie  de  la  Menopause,  and  of  which  he  has  seen 
four  cases.  The  age  of  his  patients  varied  from  46  to  50  years. 
They  were  all  vigorous  women,  free  from  hysterical  symptoms,  and 
they  had  never  suffered  from  rheumatism  or  from  any  functional 
disturbance  of  the  heart.  In  all  these  cases  the  cardiac  disorder 
occurred  at  a  time  of  life  when  menstruation  still  continued,  but  had 
already  become  somewhat  irregular.  Usually  the  trouble  in  question 
makes  its  first  appearance  during  the  flow,  or,  if  occurring  inde- 
pendently of  menstruation,  becomes  more  severe  at  that  time.  Prior 
to  the  development  of  the  actual  heart  symptoms,  we  observe  for  a 
time,  two  or  three  months  it  may  be,  signs  of  general  exhaustion 
and  weakness.  Then  occurs  an  attack  of  palpitation  of  the  heart, 
rapidly  succeeded  by  faintness,  sense  of  precordial  anxiety,  and 
dyspnoea.  During  repose  the  patient  does  not  usually  suffer  from 
any  difficulty  in  breathing,  but  sleep  is  apt  to  be  disturbed  by 
paroxysms  of  palpitation  and  severe  precordial  anxiety.  As  the 
disease  advances,  dyspnoea  is  observed  on  the  slightest  exertion. 
Ultimately,  the  symptoms  mentioned,  palpitation,  precordial  anxiety 
and  dyspnoea,  become  permanent,  but  are  less  severe  when  the 
patient  is  at  rest.  Constant  now  is  also  the  feeling  of  weakness  and 
faintness,  which  from  time  to  time  increases  to  actual  syncope  with 
complete  loss  of  consciousness,  and  coldness  of  the  entire  surface  of 
the  body.  Examination  of  the  heart  gives  negative  results.  The 
cardiac  impulse  is  a  little  stronger  than  normal ;  the  cardiac  rhythm 
may  be  either  regular  or  irregular,  but  actual  interrriission  of  the 
beats  does  not  occur.  The  heart-sounds  are  pure,  there  is  no  mur- 
mur; the  first  sound,  if  altered  at  all,  will  be  stronger,  not  weaker 
than  normal.  Neither  swelling  of  the  jugular  veins  nor  venous  pul- 
sation is  to  be  observed.  The  most  striking  symptom  of  heart 
affection,  indeed  the  only  positive  physical  sign,  is  the  great  increase 
in  the  frequency  of  the  heart's  action,  the  pulse  rate  often  being  as 
much  as  150  or  160  per  minute,  and  in  addition  weak  and  somewhat 
variable  in  strength.  At  the  outset  of  the  disease,  no  oedema  of 
the  lower  extremities  is  to  be  observed,  and  it  only  appears  after 
three  or  four  attacks.  In  all  the  patients  the  extreme  pallor  of  the 
face  is  a  striking  feature.  An  increased  quantity  of  urine  is  elimi- 
nated. The  course  of  the  disease  is  characterized  by  a  series  of  sue- 


630  THE  SEXUAL  LIFE  OF  WOMAN. 

cessive  paroxysms,  separated  by  periods  of  almost  complete  remis- 
sion. At  first,  these  remissions  last  for  a  month  or  two,  but  they 
gradually  become  shorter  and  shorter,  whereas  the  duration  of  the 
attacks  continually  increases,  until  it  is  as  much  as  seven  or  eight 
days.  At  this  stage,  disturbance  of  digestion  ensues,  the  appetite  is 
lost,  and  the  general  vigour  declines.  Recovery  ultimately  occurs, 
but  very  gradually.  Clement  refers  the  disease  to  a  profound  dis- 
turbance of  the  cardiac  innervation  through  the  sympathetic  nerves, 
but  believes  that  anaemia  constitutes  a  contributory  cause  of  the 
cardiac  disorder. 

Kostkenitsch  has  made  observations  regarding  the  influence  of  the 
climacteric  upon  previously  existing  heart-disease,  and  has  thereby 
been  led  to  conclude  that  the  influence  is  unfavourable.  The  func- 
tional disturbances  of  the  cardio-vascular  apparatus  which  commonly 
accompany  the  menopause,  readily  lead,  should  organic  heart-disease 
exist,  to  the  onset  of  severe  cardiac  weakness,  which  may  have  a 
rapidly  fatal  termination.  In  55.5^  of  the  women  who  enter  the 
climacteric  period  with  organic  disease  of  the  heart,  the  menopause 
gives  rise  to  a  failure  of  compensation.  Such  failure  of  compensa- 
tion is  especially  likely  to  occur  in  women  suffering  from  valvular 
insufficiency ;  it  is  least  probable  in  cases  of  arterio-sclerosis  without 
valvular  defect.  The  symptoms  of  defective  compensation  —  dila- 
tation of  the  heart,  increased  frequency  of  the  pulse,  arrhythmia 
cordis,  etc. —  are  manifested  especially  during  the  menstrual  flow. 

Diseases  of  the  Digestive  Organs. 

The  congestions  which,  as  we  have  already  pointed  out,  constitute 
the  pathological  basis  of  the  majority  of  the  disorders  of  the  climac- 
teric, manifest  themselves  in  the  abdominal  organs  in  the  well-known 
form  of  plethora  abdominalis,  chronic  venous  congestion  of  the  gas- 
tric and  intestinal  mucous  membrane,  hyperaemia  of  the  liver, 
hyperaemia  of  the  mucous  membrane  of  the  bladder,  catarrh  of  the 
bladder,  distension  of  the  haemorrhoidal  veins,  and  the  various 
symptoms  dependent  upon  these  several  forms  of  congestion. 

Bleeding  from  the  haemorrhoidal  veins  and  chronic  diarrhoea  are 
two  of  the  troubles  proceeding  from  the  above  mentioned  congestion 
of  the  intra-abdominal  vessels,  which  occur  so  frequently  during 
the  climacteric  period  that  since  the  days  of  antiquity  they  have  been 
regarded  as  critical  manifestations  of  the  menopause,  the  object  of 
which  is  to  afford  a  vicarious  outlet  for  the  menstrual  flux,  now 
become  irregular  and  intermittent.  It  can,  indeed,  be  readily  under- 
stood that  a  discharge  of  blood  and  an  increased  secretion  from  the 
mucous  membrane  of  the  lower  part  of  the  intestine  may,  if  not  too 
violent,  exercise  a  favourable  influence  upon  the  congestive  states 


SEXUAL  EPOCH  OF  THE  MENOPAUSE.  631 

of  the  climacteric,  by  relieving  the  distension  of  the  abdominal  ves- 
sels —  by  a  local  blood-letting  which  regulates  the  disordered  circu- 
lation. In  this  way,  even  though  we  have  ceased  to  regard  it  as  a 
''  critical "  manifestation,  haemorrhoidal  bleeding,  accompanied  by 
an  increased  secretion  from  the  intestinal  mucous  membrane,  may 
at  the  climacteric  period  have  a  distinctly  favourable  influence  upon 
a  woman's  general  condition. 

Hippocrates  already  in  his  aphorisms  pointed  out  the  salutary 
effect  of  epistaxis  and  of  diarrhoea  in  women  suffering  from  sup- 
pression of  the  menses.  Other  authors  have  assigned  a  critical 
significance  to  diarrhoeas  occurring  at  the  climacteric,  and  have 
warned  against  their  suppression.  According  to  Tilt,  diarrhoea 
occurred  in  12$  of  all  women  of  this  age  coming  under  his  observa- 
tion ;  in  4$  of  the  climacteric  women,  this  diarrhoea  recurred  at  regu- 
lar monthly  intervals,  whilst  in  8<£,  the  recurrence  was  irregular.  In 
500  women  during  the  climacteric  age,  Tilt  observed  the  following 
abdominal  disorders: 

Swollen   haemorrhoids   in 62  cases 

Diarrhoea   in 60  cases 

Enduring  disturbance  of  the  biliary  secretion  in 56  cases 

Bleeding  haemorrhoids   in 24  cases 

Intestinal  haemorrhages  in 20  cases 

Icterus   in    6  cases 

Haematemesis   in    4  cases 

Monthly  intestinal  haemorrhages  in 2  cases 

Monthly  bleeding  from  haemorrhoids  in I  case 

In  my  own  observation,  constipation  is  more  frequent  in  climac- 
teric women  than  diarrhoea,  the  constipation  being  also  a  symptom 
of  abdominal  congestion.  Sometimes,  when  diarrhoea  occurs,  it  is 
really  secondary  to  constipation.  The  accumulation  of  the  faecal 
masses  stimulates  the  intestinal  mucous  membrane,  and  gives  rise  to 
a  profuse  aqueo-mucous  secretion ;  the  firm  faecal  masses  are  then 
liquefied,  the  intestinal  wall  is  lubricated,  and  the  constipation  gives 
place  to  diarrhoea  lasting  perhaps  for  several  days.  This  is  the  ex- 
planation of  many  cases  in  which  there  is  a  periodic  recurrence  of 
diarrhoea. 

Dyspeptic  disturbances  are  rarely  absent  during  the  climacteric 
period.  Most  often  we  see  disordered  appetite,  sluggish  digestion, 
pyrosis,  eructation,  at  times  nausea  and  retching,  and  actual  vomit- 
ing of  a  watery  or  bilious  fluid.  Occasionally,  an  abnormal  sensa- 
tion of  hunger  follows  each  meal,  associated,  however,  with  a  feeling 
of  distension  of  the  stomach.  A  very  distressing  symptom  is  an 
excessive  formation  of  gas  within  the  intestine.  At  times  such 
meteorism  is  extreme,  and  it  then  gives  rise  to  very  severe  abdomi- 
nal pain.  The  gas  is  evacuated  slowly  and  with  difficulty,  the 
patient  is  compelled  to  loosen  all  her  clothing ;  more  especially  after 


632  THE  SEXUAL  LIFE  OF  WOMAN. 

a  meal  she  is  compelled  to  take  off  her  stays  and  undo  all  the  bands 
of  her  petticoats  and  skirt.  At  the  same  time  we  see  difficulty  in 
breathing  and  tachycardia.  Such  an  accumulation  of  gas  within 
the  abdomen  may  give  rise  to  serious  errors  in  diagnosis,  the  swell- 
ing being  attributed  to  pregnancy  or  to  abdominal  tumour. 

Noteworthy  also  at  the  time  of  the  menopause  is  the  occurrence 
of  vomiting,  either  as  an  isolated  symptom,  or  in  association  with 
some  other  well-known  climacteric  disorder.  When  this  vomiting 
is  associated  with  some  unmistakable  form  of  excessive  secretory 
activity  (hyperhydrosis,  etc.),  we  may  readily  suppose  that  the 
vomiting  is  due  to  undue  secretory  activity  on  the  part  of  the  gas-trie 
mucous  membrane.  An  excessive  production  of  gastric  juice,  per- 
haps altered  in  quality  as  well  as  quantity,  combined  with  some  other 
disorder  of  gastric  innervation  (hyperaesthesia,  or  hyperkinesia) 
will  sufficiently  explain  the  occurrence  of  the  sometimes  excessive 
vomiting,  even  though  in  many  of  the  cases  there  may  be  no  reason 
to  suppose  that  there  exists  any  primary  stimulation  of  the  vomiting 
centre.  In  other  cases,  however,  it  is  probable  that  the  trouble  is 
really  clue  to  a  primary  disorder  of  that  centre ;  and  a  careful  study 
of  the  clinical  features  of  the  case  will  be  needed  to  show  how  far 
there  may  be  associated  with  this  other  disorders  of  gastric  innerva- 
tion (Boerner). 

Disturbances  of  the  biliary  secretion,  icterus  of  greater  or  less 
severity,  are  by  no  means  rare  manifestations  of  the  abdominal  con- 
gestion of  climacteric  women,  and  such  disorders  have  also  been 
regarded  as  vicarious  processes  originated  by  the  cessation  of  the 
menstrual  flux  (Aran,  Bcnnct,  Hcnoch,  and  others.  Frcrichs  also 
has  pointed  out  that  with  the  cessation  of  menstruation  at  the  cli- 
macteric we  not  infrequently  observe  swelling  of  the  liver,  which 
disappears  when,  after  a  considerable  period,  the  menstrual  flow 
recurs  —  a  sequence  of  symptoms  which  may  be  repeated  again  and 
again  for  a  considerable  time. 

Diseases  of  the  Skin. 

The  most  characteristic  symptom  of  disorder  of  the  skin  met  with 
at  the  climacteric  period  —  one  which,  indeed,  may  be  said  to  be 
never  absent  —  is  ardor  fugax,  fugitive  heat ;  and  scarcely  less  com- 
mon is  hyperhydrosis,  an  excessive  secretion  of  -sweat.  Almost 
invariably,  at  the  commencement  of  the  menopause,  women  com- 
plain of  a  feeling  of  burning  heat,  rising  up  from  the  breast  to  the 
face ;  and  if  they  are  kept  under  observation  we  see  from  time  to 
time  a  sudden  redness  of  the  face,  and  sometimes  also  of  the  neck 
and  chest,  associated  with  the  outbreak  of  a  thin  perspiration.  More- 
over, in  nearly  all  climacteric  women,  we  notice  an  increased  secre- 


SEXUAL  EPOCH  OF  THE  MENOPAUSE.  633 

tion  of  sweat  over  the  whole  surface  of  the  body,  and  at  times  this 
secretion  is  extremely  profuse. 

In  association  with  these  symptoms  we  often  see  the  hyperaemic 
processes  in  the  skin  known  by  the  names  of  erythema  and  roseola, 
taking  the  form  of  larger  or  smaller  bright  red  patches,  which  are 
most  frequently  seen  on  the  sides  of  the  neck,  the  front  of  the  chest, 
and  the  face. 

In  many  women,  at  the  menstrual  periods,  when  the  flow  has 
become  scanty  or  has  already  entirely  ceased,  we  observe  the  occur- 
rence of  eczematous  eruptions,  which  have  for  this  reason  received 
the  distinctive  name  of  climacteric  eczema.  In  the  majority  of  these 
cases,  the  eczema  does  not  make  its  appearance  until  the  regular 
menstrual  flux  has  completely  ceased  to  occur;  and  in  the  less  com- 
mon cases  in  which  the  flow  persists  after  the  climacteric  eczema 
has  begun,  menstruation  is  rarely  regular,  but  has  begun  to  exhibit 
the  variability  and  disorder  characteristic  of  the  time  of  the  meno- 
pause. If  the  eczema  comes  on  after  the  menopause  is  completely 
established,  it  usually  appears  in  from  six  to  twelve  months  after 
the  cessation  of  the  flow ;  but  in  some  cases,  the  eruption  appears 
very  soon-  after  the  menopause,  whilst  in  others,  its  onset  may  be 
delayed  for  as  long  as  four  or  five  years.  Climacteric  eczema  is  ob- 
stinate, and  shows  no  tendency  to  spontaneous  cure.  With  regard 
to  the  localization  of  the  eruption,  Bohn  found  that  in  three-fourths 
of  the  cases  it  affected  the  hairy  scalp  and  the  ears;  Rayer  and 
Hebra  also  state  that  the  eczema  of  the  menopause  is  most  fre- 
quently seen  in  these  two  situations,  whilst  the  next  commonest 
site  for  the  eruption  is  the  face.  As  regards  other  parts  of  the  skin, 
it  is  only  that  of  the  extremities  that  is  ever  affected  by  this  disease, 
especially  the  hands  and  the  fingers,  less  often  the  forearms  or  the 
backs  of  the  feet;  it  never  appears  on  the  trunk.  With  regard  to 
the  types  of  eczema  occurring  in  connexion  with  the  menopause,  we 
see  almost  exclusively  the  squamous  and  the  weeping  forms  of  the 
disease. 

In  general,  at  the  climacteric  period,  the  skin  is  extremely  sensi- 
tive, and  devoid  of  powers  of  resistance  to  outward  noxious  influ- 
ences. Alternations  of  dampness  and  dryness  or  of  heat  and  cold 
readily  give  rise  to  redness,  infiltration,  and  the  formation  of  scales 
and  fissures  of  the  skin;  sometimes  this  occurs  merely  after  cold 
ablutions.  These  acute  stages  of  swelling,  redness,  and  vesiculation 
of  the  skin,  readily  pass  on  into  chronic  and  obstinate  dermatitis. 

Not  infrequently,  during  the  climacteric,  as  during  the  menarche, 
inflammation  of  the  sebaceous  glands  occurs,  acne,  at  times  accom- 
panied by  seborrhoeic  manifestations.  In  other  cases,  we  see  dis- 
figurations of  the  face  in  consequence  of  vascular  dilatations,  es- 
pecially on  the  nose  and  on  the  adjoining  portions  of  the  cheeks. 


634  THE  SEXUAL  LIFE  OF  WOMAN. 

rosacea,  in  which  disease  also  there  is  associated  inflammation  of  the 
sebaceous  glands.  Another  disorder  of  the  skin  of  the  face  which 
is  greatly  dreaded  by  women  at  this  time  of  life,  owing  to  the  un- 
sightly appearance  it  produces,  is  the  development  of  sinuous  dila- 
tations of  some  of  the  superficial  vessels,  at  times  associated  with 
connective  tissue  proliferation  in  the  form  of  red  or  violet-coloured 
painless  nodules. 

An  extremely  distressing  affection,  and  one  which  is  especially 
apt  to  attack  women  during  the  change  of  life,  is  the  previously 
mentioned  pruritus  genitalium.  The  itching  is  in  some  cases  con- 
fined to  the  external  genital  organs,  whilst  in  others  it  extends  into 
the  interior  of  the  vagina ;  also  it  may  pass  backwards  over  the 
perineum,  and  on  into  the  gluteal  folds.  In  some  cases,  some  local 
pathological  condition  will  be  found  to  account  for  the  disorder: 
catarrh  of  the  vagina  or  of  the  cervix  uteri ;  displacements,  inflam- 
mations, or  new-growths  of  the  uterus ;  anomalies  of  the  ovary,  the 
bladder,  or  the  urethra.  Cohnstcin  draws  attention  to  a  circular 
hyperplasia  of  the  vaginal  portion  of  the  cervix,  occurring  during 
the  menopause,  and,  "  owing  to  the  vascular  dilation  by  which  it  is 
characterized,  possessing  close  analogies  with  haemorrhoids ;"  the 
worst  symptom  of  this  affection  is  pruritus.  That  in  these  cases 
the  pruritus  is  actually  dependent  upon  the  "  haemorrhoidal 
hyperplasia "  of  the  portio  vaginalis,  Cohnstcin  considers  to  be 
proved  by  the  fact  that,  whilst  local  applications  give  no  more  than 
momentary  relief  to  the  itching,  this  symptom  is  completely  relieved 
by  the  abstraction  of  blood  from  the  cervix.  But  in  addition  to  such 
cases  as  these,  we  have  from  time  to  time  to  deal  with  patients  suf- 
fering from  violent  genital  pruritus  during  the  climacteric  period,  in 
whom  we  shall  vainly  seek  for  any  local  pathological  changes,  to 
the  cure  of  which  our  therapeutic  zeal  may  be  directed.  Analogy 
with  some  other  disorders  of  the  climacteric  leads  us  to  conclude 
that  in  these  cases  also  we  have  to  do  with  an  idiopathic  neurosis 
(Bocrncr). 

The  frequent  recurrence  of  pruritus  vulvae  leads  ultimately  to  the 
formation  of  nodules  and  papular  eruptions. 

Many  authors  state  that  they  have  observed  the  frequent  occur- 
rence of  erysipelas  during  the  climacteric  period ;  others  assert  that 
furunculosis,  prurigo,  urticaria,  and  herpes  zoster,  are  seen  with 
especial  frequency  at  this  period  of  life. 

Tilt,  in  his  500  cases  of  women  at  the  climacteric  age,  made  the 
following  observations : 

201,  or  40.2^,  suffered  from  heats  and  tendency  to  perspiration. 

2,  or  0.4^,  suffered  from  monthly  recurrence  of  periods  of  perspi- 
ration. 


SEXUAL  EPOCH  OF  THE  MENOPAUSE.  635 

84,  or  i6.8#,  suffered  from  profuse  perspirations. 

13,  or  2.6$,  suffered  from  cold  sweats. 

14,  or  2.8^,  suffered  from  dry  heats  (dry  flushes). 

1 86,  or  37.2^,  remained  free  from  such  attacks  of  heat  or  per- 
spiration. 

Krieger  gives  as  an  example  of  the  "  occurrence  of  new  troubles  " 
at  the  change  of  life,  furunculosis ;  so  also  does  Bocrncr.  "  The  dis- 
colouration of  the  face,  occurring  usually  in  connexion  with  preg- 
nancy or  with  diseases  of  the  reproductive  organs,  and  known  as 
chloasma  uterinum,  has  been  seen  by  Cohnstein,  during  the  climac- 
teric period,  "  chiefly  in  cases  in  which,  owing  to  some  degree  of 
failure  of  general  nutrition,  the  skin  has  been  thrown  into  folds." 
Wilson  regarded  prurigo  and  eczema  as  the  commonest  skin-dis- 
eases of  the  climacteric  period ;  whilst  Bocrner  draws  attention  to  a 
connexion  between  climacteric  conditions  and  the  outbreak  of 
herpes  zoster. 

Disorders  of  Metabolism. 

Among  the  disorders  of  metabolism  to  which  women  are  es- 
pecially prone  at  the  climacteric  period,  we  must  in  the  first  place 
allude  to  obesity  (lipomatosis  universalis),  and  to  gout  (arthritis 
urica). 

Numerous  observations  have  shown  us  that  the  time  of  the  change 
of  life,  the  period  between  the  ages  of  40  and  50  years,  is  the  one 
especially  favourable  in  women  to  the  extensive  deposit  of  fat  in 
the  tissues. 

In  200  cases  of  great  obesity  (lipomatosis  universalis)  in  women, 
in  which  I  instituted  enquiries  regarding  the  age  at  which  an  exces- 
sive deposit  of  fat  in  the  tissues  had  first  been  noticed,  I  obtained 
the  following  results : 

In  early  childhood  in 19  cases 

At  the  age  between  15  and  20  years  in 30  cases 

At  the  age  between  20  and  30  years  in 45  cases 

At  the  age  between  30  and  40  years  in 52  cases 

At  the  age  between  40  and  50  years  in 54  cases 

At  ages  over  50  years o  cases 

We  learn  from  these  figures  that  it  'is  between  the  ages  of  40  and 
50  years  that  there  is  the  greatest  tendency  in  women  for  the  accu- 
mulation of  fat ;  but  that  as  early  as  between  the  ages  of  30  and  40 
years  this  accumulation  may  in  many  instances  begin.  Speaking 
generally,  there  is  in  women  an  obvious  connexion  between  the  de- 
velopment of  obesity  and  the  state  of  the  reproductive  functions, 
inasmuch  as  at  puberty,  during  the  puerperium,  and  above  all  at 
the  climacteric,  there  is  a  special  tendency  to  the  accumulation  of 
fat  in  the  subcutaneous  tissues.  At  the  commencement  of  the  meno- 


636  THE  SEXUAL  LIFE  OF  WOMAN. 

pause,  it  is  more  especially  in  the  abdominal  wall,  the  breasts,  and 
the  buttocks,  that  we  witness  the  deposit  of  fat.  In  the  abdomen, 
owing  to  the  thickening  of  the  subcutaneous  tissues  and  of  the  great 
peritoneal  folds  —  especially  of  the  great  omentum  —  a  marked  pro- 
trusion occurs,  whilst  the  umbilicus  becomes  more  deeply  hollowed, 
and  ultimately  funnel-shaped.  In  some  instances,  the  deposit  of  fat 
around  the  navel  favours  the  occurrence  of  umbilical  hernia.  After 
an  artificial  menopause,  induced  by  oophorectomy,  it  has  also  been 
noticed  in  from  42  to  52$  of  the  cases  that  a  marked  general  deposit 
of  fat  has  occurred,  affecting  especially  the  breasts  and  the  buttocks. 

This  obesity  in  climacteric  women,  not  only  impairs  to  a  serious 
extent  their  good  looks,  but  brings  in  its  train  a  number  of  troubles, 
and  gives  rise  to  manifold  morbid  manifestations,  and  among  these, 
changes  in  the  heart,  which  may  readily  threaten  the  patient's  life. 
In  consequence  of  extensive  fatty  deposits  in  the  myocardium,  asso- 
ciated with  actual  fatty  degeneration  of  the  muscular  fibres,  cardiac 
insufficiency  ensues,  with  all  its  distressing  and  disastrous  conse- 
quences. It  is  further  necessary  to  insist  upon  the  fact  that  obesity 
during  the  climacteric  very  definitely  favours  the  occurrence  of 
menorrhagia. 

On  examining  282  women,  5  years  after  the  complete  cessation  of 
the  menstrual  flow,  Tilt  found  that 

121  had  become  stouter  than  before, 
71  were  unchanged  in  this  respect,  and  that 
90  were  thinner  than  formerly. 

Alike  in  the  third  class  and  in  the  first  were  a  very  large  pro- 
portion of  women  in  whom  the  change  of  life  had  entailed  much 
illness  and  suffering;  but  in  the  first  class,  the  women  who  had 
been  thus  affected  had  at  that  time  lost  weight,  and  only  in  the 
latter  half  of  the  climacteric  period,  when  their  troubles  had  become 
less  severe,  had  the  condition  of  embonpoint  made  its  appearance. 

Passing  now  to  the  consideration  of  arthritis  urica  in  women  at 
the  climacteric,  it  is  worthy  of  mention  that  Hippocrates  was  so 
much  struck  by  the  association  that  he  went  so  far  as  to  deny  that 
gout  occurred  at  all  in  women  before  the  menopause.  The  fact  of 
the  matter  is  that  whilst  women  are  in  general  less  disposed  than 
men  to  the  occurrence  of  gout,  the  tendency  of  women  to  this 
disease  during  the  climacteric  period  is  so  marked,  that  at  this  epoch 
of  life  the  disease  is  far  more  common  in  women  than  it  is  in  men 
of  corresponding  age. 

It  is  in  obese  women,  with  a  soft,  white,  and  lax  integument,  with 
a  pallid,  somewhat  bloated  countenance,  a  poorly  developed  mus- 
cular system,  extensive  varicosities  of  the  veins  of  the  legs,  marked 


SEXUAL  EPOCH  OF  THE  MENOPAUSE.  637 

dyspeptic  troubles,  and  habitual  constipation,  that  during  the  pre- 
climacteric  and  climacteric  periods,  gout  is  especially  apt  to  make  its 
appearance.  It  is  then  characterized  by  the  following  symptoms. 
From  time  to  time  the  woman  suffers  from  tearing  or  shooting 
pains  in  the  joints,  lasting  at  first  a  short  time  only,  and  returning 
after  longer  or  shorter  intervals.  With  the  frequent  return  of  the 
pains,  the  affected  joints  become  swollen;  and  finally  the.  patient 
suffers  from  the  characteristic  attacks  of  acute  gouty  arthritis,  with 
the  well-known  consecutive  symptoms  of  this  affection. 

According  to  the  observations  of  Geist,  during  the  climacteric 
period,  28  women  suffer  from  gout  as  compared  with  4  men  of  cor- 
responding age.  Tilt  publishes  the  following  figures  showing  the 
mortality  of  women  from  gout  in  England : 

At  ages  from  20  to  30  years 56  women 

At  ages  from  30  to  40  years 121  women 

At  ages  from  40  to  50  years 291  women 

At  ages  from  50  to  60  years 152  women 

At  ages  from  60  to  70  years 104  women 

Regarding  diabetes  mellitus  during  the  menopause,  Lawson  Tail, 
who  maintained  there  was  a  distinct  form  of  climacteric  diabetes, 
asserted  that  this  disorder  of  metabolism  was  less  severe,  and  runs 
a  longer  course  during  the  climacteric  period  than  at  other  times 
of  life. 

Diseases  of  the  Nervous  System. 

The  disturbances  of  the  nervous  system  that  occur  during  the 
climacteric  period,  manifest  themselves  chiefly  in  the  form  of 
hyperaesthesia  and  hyperkinesia.  The  sensory  nerves  appear  to 
me  for  the  most  part  to  be  more  irritable  than  normal,  inasmuch  as 
every  stimulus  by  which  they  are  affected  arouses  a  comparatively 
greater  sensation,  and  gives  rise  to  an  excessive  reaction  in  the 
sphere  of  consciousness.  The  cutaneous  hyperaesthesia  of  climac- 
teric women  is  shown  in  very  various  ways,  the  commonest  being 
the  anomaly  of  sensation  which  gives  rise  to  the  symptom  known 
as  pruritus,  characterized  by  paroxysms  of  itching  in  more  or 
less  extensive  areas  of  skin,  with  consecutive  nutritive  changes  in 
the  affected  portions  of  the  integument.  The  commonest  and  the 
most  distressing  form  of  this  disorder  during  the  menopause  is 
pruritus  vnlvae. 

In  addition  to  such  manifestations  of  cutaneous  hyperaesthesia, 
vasomotor  disturbances  of  the  skin  are  of  frequent  occurrence, 
characterized  by  redness,  rise  of  temperature,  and  sometimes  the 
formation  of  nodules  in  the  affected  areas.  Almost  without  ex- 
ception, at  the  outset  of  the  climacteric  period,  and  sometimes  also 


638  THE  SEXUAL  LIFE  OF  WOMAN. 

in  the  preclimacteric  epoch,  women  complain  of  a  very  distressing 
feeling  of  fugitive  heat  in  various  portions  of  the  surface  of  the 
body,  manifested  objectively  by  the  rapid  appearance  and  no  less 
rapid  subsidence  of  a  red  colouration  of  the  skin  of  the  face,  the 
neck,  and  the  chest.  Such  fugitive  heats  are  due  to  disturbances  of 
vasomotor  innervation  giving  rise  to  sudden  variations  in  the 
amount  of  blood  passing  through  the  vessels  of  the  affected  areas 
of  skin. 

Hardly  less  frequent  during  the  climacteric  are  the  sensations  of 
imaginary  movement  which  give  rise  to  the  subjective  symptom 
known  as  vertigo.  Often  in  women  at  this  time  of  life  it  occurs 
quite  without  apparent  cause,  but  in  other  cases  on  the  performance 
of  some  unusual  movement  or  the  adoption  of  some  unusual  posture ; 
there  is  a  sudden  perception  of  rotatory  movement,  either  of  the 
patient's  own  body  or  else  of  her  visible  and  palpable  environment. 
With  this  feeling  of  disturbed  equilibrium,  there  is  often  associated 
optical  and  auditory  hyperaesthesia,  flickering  before  the  eyes 
(muscae  volitantes),  tinnitus  aurium,  painful  sensations  in  the  head 
and  more  especially  in  the  occipital  region,  nausea,  vomiting,  sense 
of  anxiety,  cold  sweats,  muscular  twitchings,  alternating  redness 
and  pallor  of  the  face,  and  coldness  of  the  feet.  The  vertigo  occurs 
in  paroxysms,  usually  of  short  duration,  varying  from  one  to  fifteen 
minutes.  It  is  especially  in  plethoric  and  .obese  women  that  climac- 
teric vertigo  occurs. 

A  peculiar  form  of  this  .climacteric  vertigo  is  that  described  by 
Tilt  under  the  name  of  "  Pseudo-Narcotism  "  of  climacteric  women, 
characterized  by  a  sense  of  swimming  movements,  uncertainty  in 
the  gait,  vacancy  of  expression,  a  confused  look  in  the  eyes  like 
those  of  a  drunken  person,  and  a  kind  of  mental  stupor  which  the 
patient  cannot  shake  off  without  considerable  effort.  The  women 
thus  affected  state  that  they  feel  as  if  they  had  had  too  much  to 
drink,  as  if  something  had  gone  to  their  heads ;  indeed  their  great 
fear  is  that  they  will  be  supposed  to  be  intoxicated  by  those  who 
see  them  walking  in  the  streets;  they  feel  even  that  they  must  re- 
fuse to  receive  the  visits  of  their  acquaintances  if  they  wish  to  pre- 
serve their  reputation  for  sobriety.  They  suffer  also  from  great 
drowsiness,  from  a  disagreeable  sense  of  weight  or  pressure  in  the 
head,  from  a  feeling  "  as  if  the  brain  was  clouded,  or  needed  to 
have  some  cobwebs  swept  away."  They  feel  a  disinclination  to 
both  mental  and  physical  exertion,  and  their  memory  and  all  other 
intellectual  powers  are  impaired. 

Boerner  maintains  that  the  attacks  of  vertigo  so  frequently  occur- 
ring at  the  menopause  are  in  a  minority  of  cases  only  dependent 
upon  hyperaemic  states  (arising  from  the  cessation  of  the  menstrual 
flow)  ;  on  the  contrary,  he  believes  that  the  cause  more  often  lies 


SEXUAL  EPOCH  OF  THE  MENOPAUSE,  639 

in  hysteria,  in  chronic  disorder  of  the  digestive  tract,  or,  finally,  in 
anaemia.  In  his  opinion,  vertiginous  attacks  dependent  upon  cere- 
bral anaemia  are  very  common  indeed  during  the  climacteric  period, 
and  even  for  a  long  time  afterwards;  and  he  believes  that  their 
nature  is  often  completely  misinterpreted. 

Another  very  unpleasant  indication  of  disordered  nervous  func- 
tion during  the  climacteric  period  is  the  sleeplessness  that  is  so 
common  at  this  time  of  life.  Women  who  during  the  day  time  feel 
comparatively  well,  suffer  at  night,  sometimes  periodically  at  exactly 
the  same  hour  night  after  night,  from  a  state  of  general  restlessness, 
and  for  this  reason  are  unable  to  obtain  the  sleep  for  which  they 
long.  They  throw  themselves  uneasily  from  side  to  side  of  the 
bed,  or  wander  restlessly  about  the  room,  and  before  long,  owing  to 
this  want  of  sufficient  repose,  become  greatly  depressed. 

Among  the  neuroses  of  the  sensory  apparatus,  the  various  kinds 
of  cutaneous  neuralgia  are  less  common  than  during  the  menarche 
and  the  menacme ;  but  on  the  other  hand,  in  my  personal  experience 
at  any  rate,  the  visceral  neuralgias  are  commoner,  more  especially 
cardialgia  and  hypogastric  neuralgia.  Of  the  superficial  neuralgias, 
hemicrania  and  intercostal  neuralgia  are  those  which  occur  most 
often  during  the  climacteric  period. 

During  the  change  of  life,  hemicrania  most  commonly  occurs  in 
typical  association  with  menstruation;  or,  if  the  flow  has  already 
ceased,  the  attacks  of  hemicrania  recur  at  what  should  be  the 
menstrual  periods.  This  affection  is  characterized  by  the  paroxys- 
mal occurrence  of  a  severe  boring  pain  in  the  side  of  the  head,  more 
often  the  left  side  than  the  right,  affecting  the  temporal,  the.  parietal, 
or  the  occipital  region,  or  the  entire  side  of  the  calvaria  at  once, 
usually  accompanied  with  redness  and  local  rise  of  temperature  of 
the  painful  part;  the  duration  of  the  paroxysms  varies  in  different 
cases  from  one  or  two  to  many  hours ;  with  the  pain  are  associated 
chilliness,  nausea,  exhaustion,  and  a  severe  feeling  of  general 
malaise. 

Of  the  intercostal  neuralgias,  one  form  deserves  especial  mention 
in  this  connexion:  I  refer  to  mastodynia,  which  is  both  physically 
and  mentally  one  of  the  most  distressing  affections  to  which  women 
are  subject  during  the  climacteric  period.  For  a  middle-aged 
woman  suffering  from  mastodynia  —  the  "  irritable  breast "  of 
Cooper  —  almost  invariably  feels  assured  that  these  pains  localized 
in  the  breast  and  its  immediate  vicinity  are  indications  of  a  com- 
mencing cancer  of  the  breast;  and  it  is  an  exceedingly  difficult 
matter,  in  most  cases,  to  convince  her  that  her  fears  are  without 
foundation.  In  this  manner,  partly  in  consequence  of  the  directly 
depressing  effect  of  the  pains,  which  are  commonly  intensely  severe, 
and  partly  owing  to  the  disturbance  of  mind  produced  by  the  belief 


640  THE  SEXUAL  LIFE  OF  WOMAN. 

that  an  incurably  fatal  disorder  has  begun,  I  have  in  several  in- 
stances seen  cases  of  profound  melancholia  originate. 

According  to  Windscheid,  among  the  enduring  painful  sensations 
of  the  climacteric  period,  pains  in  the  lower  extremities  are  of  some- 
what frequent  occurrence.  Day  after  day  the  patient  suffers  from 
distressing  tearing  or  lancinating  sensations  in  the  legs ;  the  trouble 
is  insusceptible  of  more  exact  description,  but  is  none  the  less  a 
very  severe  one.  In  addition  to  the  lower  extremities,  the  back,  the 
spinal  column,  and  more  particularly  the  lumbo-sacral  region,  are 
often  the  seats  of  incessant  pain.  In  the  thoracic  region  of  the 
back,  the  pain  is  usually  diffuse ;  when  confined  to  the  spinal  column, 
however,  it  is  commonly  limited  to  individual  vertebrae,  the  spinous 
processes  of  those  affected  being  also  sensitive  to  pressure.  The 
sacral  pains  may  in  some  cases  predominate  to  such  an  extent,  that 
it  is  on  this  ground  alone  that  the  patient  comes  to  seek  medical 
advice.  The  sacrache  is  equally  severe  when  the  patient  is  stand- 
ing, sitting,  or  recumbent ;  it  often  radiates  into  the  lower  extrem- 
ities. Boerncr  draws  attention  to  the  fact  that  in  many  cases  the 
pains  in  the  sacrum  or  higher  up  in  the  back  may  be  due  to  exces- 
sive tension  of  the  abdominal  parietes  in  consequence  of  the  great 
accumulation  of  fat.  Among  motor  manifestations,  Windscheid 
draws  especial  attention  to  a  certain  degree  of  weakening  of  the 
muscles  of  the  lower  extremities.  Although  on  examination  no 
abnormality  can  be  detected,  fatigue  and  functional  incapacity, 
more  especially  in  the  lower  extremities,  ensue  in  a  manner  alto- 
gether disproportionate  to  the  exertion,  so  that  the  patient  is  most 
unwilling  to  take  even  a  short  walk,  to  go  upstairs,  etc.  In  pro- 
nounced cases,  the  patient  will  never  go  out  walking  without  carry- 
ing a  campstool,  so  that  she  can  sit  down  to  rest  directly  she  begins 
to  feel  fatigued.  In  association  with  these  disorders  of  motility  we 
most  commonly  see  the  above-mentioned  painful  sensations  in  the 
legs,  and  by  these  latter  the  functional  incapacity  of  the  lower 
limbs  is  of  course  increased.  Weakness  of  the  arms  is  far  less 
frequently  observed;  but  occasionally  we  hear  complaints  that  on 
the  performance  of  domestic  duties,  needlework,  etc.,  which  pre- 
viously could  be  carried  out  quite  easily,  the  arms  and  hands  are 
now  speedily  fatigued,  and  rendered  functionally  incapable. 

Of  the  visceral  neuralgias,  cardialgia  is  by  no  means  rare  during 
the  climacteric  period ;  the  pain  is  concentrated  in  the  epigastric 
region,  but  not  infrequently  radiates  to  the  back  and  fo  the  chest. 
Hypogastric  neuralgia  is  also  not  uncommon,  pain  in  the  lower  part 
of  the  abdomen,  associated  with  a  sense  of  pressure  in  the  bladder, 
the  uterus,  and  the  rectum,  and  sometimes  radiating  to  the  thighs 
and  to  the  region  of  the  haemorrhoidal  nerves. 

The  opinion  expressed  by  several  authorities,  that  the  menopause 


SEXUAL  EPOCH  OF  THE  MENOPAUSE.  641 

favours  the  occurrence  of  cerebral  apoplexy,  must,  according  to 
Windscheid,  be  received  with  caution;  we  have  to  remember  that 
with  advancing  years  atheromatous  changes  are  apt  to  occur  in  the 
cerebral  arteries,  and  it  is  to  these  changes,  altogether  indepen- 
dently of  the  climacteric,  that  cerebral  haemorrhage  is  due.  It 
appears,  however,  to  be  a  fact  that  the  menopause  favours  the  onset 
of  progressive  paralysis.  According  to  Jung,  60^,  and  according 
to  ron  Krafft-Ebing,  27$,  of  women  affected  with  paralysis  were 
first  affected  in  this  way  during  the  climacteric  period.  Von  Krafft- 
Ebing  explains  this  occurrence  by  the  fact  that  during  the  meno- 
pause fluxions  of  vasomotor  origin  are  common,  and  these  serve 
as  the  starting  point  of  transudative  processes. 

Among  the  neuropathic  manifestations  of  the  climacteric  period 
we  must  reckon  the  at  times  excessive  increase  of  the  sexual 
impulse.  We  have  already  insisted  upon  the  fact  that  the  sexual 
impulse  is  not  normally  extinguished  in  women  at  the  time  of  the 
cessation  of  menstruation ;  on  the  contrary,  sexual  desire  commonly 
persists  long  after  the  menopause,  and  on  this  fact  is  largely  de- 
pendent the  frequency  with  which  elderly  women  espouse  quite 
young  men.  But  in  some  cases,  the  sexual  impulse  is  enormously 
enhanced  during  the  climacteric  period,  and  the  patient  experiences 
paroxysms  of  intense  voluptuous  sensation,  associated  with  mani- 
festations of  abnormal  reflex  and  psychical  reaction,  with  increased 
frequency  of  the  pulse  and  the  respiration,  emotional  excitement, 
it  may  be  loss  of  consciousness,  and  even  general  convulsions. 
Some  of  these  cases  of  disordered  sexuality  occur  in  those  pre- 
viously affected  with  pruritus  vulvae  et  vaginae. 

More  particularly  Guenceau  de  Mussy  and  Bocrner  have  described 
cases  of  such  excessive  libido  sexualis  during  the  climacteric 
period,  voluptuous  crises  with  pollutions,  occurring  independently 
of  any  external  cause ;  the  women  thus  affected  have  a  continued 
succession  of  erotic  ideas,  they  experience  an  itching  and  burning 
sensation  in  the  genital  organs,  and  from  time  to  time  this  cul- 
minates in  a  paroxysm  of  sexual  feeling,  with  orgasm,  and  increased 
secretion  from  the  glands  of  the  vulva. 

Bocrner  has  observed  that  characteristic  variations  in  the  libido 
sexualis  commonly  occur  at  the  climacteric  period.  Net  infre- 
quently at  this  time  the  sexual  desire  becomes  greatly  diminished 
in  intensity,  or  even  entirely  disappears ;  more  often,  however,  the 
desire  persists  throughout  this  epoch;  finally,  in  many  instances, 
the  desire  undergoes  an  increase,  at  times  to  a  degree  amounting 
to  positive  torment.  The  first  of  these  changes,  the  decline  in  the 
intensity  of  the  sexual  desire,  harmonising  as  it  does  with  the 
general  extinction  of  the  sexual  functions  at  the  change  of  life, 

41 


642  THE  SEXUAL  LIFE  OF  WOMAN. 

might  have  been  expected  to  be  the  normal  occurrence.  And  it  is 
a  fact  that  in  many  cases  characterized  by  an  increase  of  libido 
sexualis  at  the  climacteric  epoch,  Boerner  found  that  there  ex- 
isted anatomical  abnormalities  in  the  reproductive  organs  (fib- 
romata, flexions,  etc.).  Be  this  as  it  may,  an  increase  in  the  inten- 
sity of  sexual  desire,  as  long -as  that  increase  is  not  altogether 
excessive,  may  be  regarded  as  one  manifestation  of  the  visceral 
hyperaesthesias  so  general  at  this  time  of  life.  In  the  excessive 
degrees  of  this  affection,  however,  those  in  which  at  times  the 
sexual  crisis  is  associated  with  general  convulsions,  we  must,  with 
Romberg,  recognize  the  existence  of  a  direct  neuralgic  state  of  the 
spermatic  plexus.  It  is  especially  before  the  commencement  of  an 
actual  menstrual  period,  or  before  a  due  period  which  fails  to 
occur,  that  during  the  critical  years  complaint  is  made  of  this  state 
of  excessive  sexual  desire  and  sensibility;  and  in  many  instances 
the  trouble  begins  at  the  very  first  appearance  of  the  menstrual 
irregularities  which  foreshadow  the  menopause. 

Windschcid  draws  attention  to  the  fact  that  occasionally  the 
nervous  manifestations  may  make  their  appearance  prior  to  the 
occurrence  of  any  menstrual  irregularity,  so  that  it  is  by  the  nervous 
disturbance  that  the  woman  or  her  physician  is  warned  of  the 
approach  of  the  menopause.  "  When  the  menstrual  anomalies 
begin,"  continues  Windschcid,  "  that  is  to  say,  at  the  commence- 
ment of  the  climacteric,  the  nervous  troubles  may  have  already 
attained  their  maximum  and  have  begun  to  decline  in  intensity. 
As  a  general  rule,  however,  the  appearance  of  the  nervous  dis- 
turbances coincides  with  the  commencement  of  the  menstrual  irreg- 
ularities. It  may  happen  that  these  disturbances  are  intensified 
with  each  recurring  period,  but  this  is  not  the  rule.  Sometime's, 
however,  we  may  observe  that  when  menstruation  occurs  with  ex- 
cessive frequency  —  a  by  no  .means  rare  phenomenon  at  the 
outset  of  the  climacteric  —  the  nervous  disturbances  become  more 
severe ;  and  especially  is  this  the  case  when  the  unduly  frequent 
flow  is  also  abnormally  profuse,  as  indeed  often  happens."  The 
manifestations  of  climacteric  neurosis  occur,  as  Windschcid  rightly 
insists,  most  frequently  in  the  sphere  of  the  psyche.  "  We  observe 
a  change  in  the  disposition,  which  usually  becomes  more  excitable. 
A  woman  previously  calm  and  composed  becomes  irritable,  in- 
clined to  emotional  disturbance  and  to  fits  of  temper,  and  unable 
to  bear  with  equanimity  the  pinpricks  so  frequent  in  daily  life,  and 
especially  in  the  daily  life  of  a  housewife.  In  other  cases,  however, 
the  disturbance  of  the  psyche  is  rather  in  the  direction  of  depres- 
sion :  we  observe  a  kind  of  spiritual  inhibition,  a  deficiency  of  vital 
energy,  an  indifference  to  things  which  formerly  gave  pleasure. 


SEXUAL  EPOCH  OF  THE  MENOPAUSE.  643 

Almost  always,  also,  complaints  of  loss  of  memory  are  among  the 
indications  of  such  depression.  To  these  intellectual  anomalies 
are  superadded  disturbances  of  sensibility.  There  is  excessive 
sensitiveness  to  bright  lights,  loud  noises,  and  strong  odours.  Fre- 
quently, also,  in  such  cases,  We  see  great  intolerance  to  alcohol, 
quite  small  doses  giving  rise  to  extremely  disagreeable  sensations  in 
the  head." 

Climacteric  Psychoses. 

The  powerful  influence  which  the  changes  occurring  at  the 
climacteric  period  has  in  the  origination  of  psychoses,  has  long 
been  recognized,  the  menopause,  in  fact,  being  a  favourable  soil 
for  the  cultivation  of  mental  disease.  The  fact  is  embodied  in 
medical  terminology,  since  many  authors  speak  of  "  climacteric  in- 
sanity," assuming  that  the  psychoses  of  this  period  of  life  present 
a  definite  and  characteristic  clinical  picture. 

In  an  earlier  part  of  this  work  it  was  shown  that  the  process 
of  menstruation  has  generally  a  marked  effect  upon  the  psyche, 
and  that  disturbances  of  menstrual  activity  are  competent  to  exer- 
cise a  pathogenic  influence  upon  the  mental  condition  of  the  woman 
who  suffers  from  them ;  still  greater  and  more  intense  is  the  in- 
fluence of  the  cessation  of  menstrual  activity,  with  its  powerful  and 
widespread  disturbance  of  the  entire  organism,  with  its  destructive 
oscillations  of  equilibrium  in  the  spheres  of  sensation,  perception, 
ideation,  and  volition.  It  is  easy  to  understand  how  the  rarer  re- 
currence of  menstruation,  the  occasional  profuse  losses  of  blood, 
the  complete  suppression  of  menstruation,  the  conditions  peculiar 
to  the  climacteric  period  of  stasis  and  congestive  hyperaemia  of  the 
brain,  are  competent,  more  especially  in  hereditarily  predisposed 
persons,  to  give  rise  to  the  development  of  psychoses;  whilst  in 
those  already  suffering  from  mental  disorder,  the  menopause  will 
be  likely  to  bring  about  an  aggravation  in  their  symptoms.  At  this 
time  of  life,  also,  we  have  to  take  into  account  the  effect  of  certain 
ideational  influences  to  which  allusion  has  already  been  made,  the 
thought  that  womanhood  and  its  joys  are  passing  away  for  ever, 
and  the  fear  of  the  dangers  attendant  upon  this  critical  period  of 
the  change  of  life.  A  French  proverb  alludes  to  "  le  diable  de 
quarante  ans,  si  habille  a  tourmenter  les  femmes." 

Mental  disorder  will  be  more  likely  to  ensue  at  the  climacteric 
period  in  those  women  whose  nervous  systems  have  always  been 
unduly  irritable,  and  in  those  affected  with  hereditary  predisposition 
to  insanity.  Further,  it  is  more  likely  to  occur  in  those  in  whom 
the  menopause  takes  place  quite  suddenly,  in  a  catastrophic  manner, 
than  in  those  in  whom  the  climacteric  proceeds  gradually,  and 


644  THE  SEXUAL  LIFE  OF  WOMAN. 

unaccompanied  by  any  stormy  manifestations  in  the  organism  at 
large. 

It  is  not  in  my  opinion  possible  to  recognize  any  specific  form 
of  mental  disorder  peculiar  to  the  climacteric  period,  but  neverthe- 
less the  psychoses  occurring  at  this*  time  of  life  do  exhibit  certain 
striking  and  characteristic  features,  more  especially  in  this  respect, 
that  states  of  mental  depression  with  melancholia  predominate, 
whilst  erotic  influences  are  manifest  in  their  etiology.  In  the 
slighter  forms,  volition  and  ideation  are  unaffected,  and  the  trouble 
manifests  itself  in  the  form  of  hypochondriacal  moods,  associated 
with  bodily  troubles.  In  more  severe  cases  we  see  emotional  de- 
pression, states  of  anxiety,  limitation  of  the  powers  of  conception 
and  judgment,  indecisiveness,  low-spiritidness,  and  apathy;  or  on 
the  other  hand,  restlessness,  an  inclination  to  continued  moving 
about,  the  eager  pursuit  of  continually  varying  occupations,  lo- 
quacity, etc.;  finally,  if  the  mental  disorder  becomes  still  more 
severe,  hallucinations,  delirium,  paroxysms  of  intense  excitement, 
and  in  exceptional  instances,  fully  developed  mania. 

As  with  regard  to  the  other  disorders  attending  the  climacteric, 
so  also  in  respect  of  the  climacteric  psychoses,  women  who  have 
been  or  are  married,  who  have  had  a  reasonable  number  of  children, 
and  have  been  accustomed  to  a  sufficiency  of  sexual  activity,  are 
more  favourably  situated,  are  far  more  immune,  than  women  whose 
sexual  circumstances  have  been  the  opposite  of  those  mentioned, 
who  have  had  one  or  two  children  only,  who  have  indulged  in 
intercourse  only  when  protected  from  pregnancy  by  the  use  of 
preventive  measures,  or  have  remained  sexually  unsatisfied,  and, 
finally,  women  who  have  never  married,  and  those  who  for  many 
years  prior  to  the  commencement  of  the  menopause  have  lived  in 
chaste  widowhood.  In  "  old  maids,"  to  the  somatic  effects  of 
sexual  abstinence  (or  in  some  cases  of  abnormal  sexual  gratifica- 
tion );  are  superadded  the  effects  of  the  intellectual  and  emotional 
recognition  of  a  wasted  life.  Again,  it  by  no  means  rarely  comes 
under  our  observation  that  women  who  in  youth,  at  the  time  of  the 
menarche,  suffered  from  psychical  disturbances,  are  apt  once  again 
to  be  affected  with  transitory  mental  disorder  at  the  change  of  life. 
Once,  however,  the  menopause  is  completely  at  an  end,  a  condition 
of  mental  quiescence  is  as  a  rule  established,  and  then  it  may  hap- 
pen.that  previously  existent  mental  disorders  undergo  amelioration; 
but  on  the  other  hand 'we  have  in  all  cases  to  reckon  with  the  pos- 
sibility that  they  may  take  an  unfavourable  turn  in  the  direction 
of  the  development  of  senile  psychoses. 

Of  considerable  interest  is  the  fact,  first  pointed  out  by  Glacrcckc, 
and  subsequently  confirmed  by  other  observers,  that  in  cases  of 
artificial  menopause,'  melancholic  mental  disturbances  not  infre- 


SEXUAL  EPOCH  OF  THE  MENOPAUSE.  645 

quently  follow  the  operation,  in  some  instances  so  severe  as  to  lead 
to  weariness  of  life  and  actual  suicide;  and  in  general,  after  the 
artificial  induction  of  the  menopause,  psychical  disturbances  are  by 
no  means  rare,  and  are  sometimes  very  severe.  .  Such  disturb- 
ance of  the  mental  balance  is  seen  after  oophorectomy  especially 
in  women  who  are  still  comparatively  young,  and  whose  sexual 
powers  are  still  in  a  ripe  state ;  whereas  when  the  operation  is  per- 
formed in  women  of  a  more  advanced  age,  whose  ovaries  were 
already  nearly  or  completely  functionless,  no  psychopathic  changes 
are  likely  to  ensue.  In  women  belonging  to  the  former  category, 
the  same  etiological  influences  come  into  operation  as  in  the 
physiological  menopause,  the  patient,  that  is,  is  affected  by  the 
psychical  influences  of  the  removal  of  the  ovaries  —  not  only  by 
the  cessation  of  menstruation  and  the  disappearance  of  the  internal 
secretion  of  the  reproductive  glands,  leading  to  a  disturbance  of 
the  physical  equilibrium,  but  also  by  the  intellectual  recognition  of 
the  loss  of  sexual  potency,  and  a  consequent  disturbance  of  the 
mental  balance. 

In  Schlage/s  opinion  the  climacteric  has  a  potent  influence  in 
promoting  the  development  of  psychical  disturbances  in  women, 
even  when  the  involution  occurs  at  the  normal  age.  The  course  of 
these  disturbances  is  as  follows:  soon  after  the  commencement  of 
the  process  of  involution,  when  for  a  few  months  already  the  men- 
strual periodicity  has  been  irregular,  or  the  flow  has  been  unduly 
profuse,  a  change  of  disposition  makes  its  appearance,  at  first 
hardly  noticeable,  but  after  a  little  time  manifesting  itself  clearly 
in  the  form  of  an  increase  in  irritability.  The  woman  finds  fault 
with  everything  and  everybody,  becomes  mistrustful,  suspicious, 
full  of  complaints,  imagines  that  the  most  insignificant  annoyances 
are  due  to  intentional  slights;  at  the  same  time  she  complains  of 
continued  sleeplessness,  palpitation,  various  indescribable  sensa- 
tions, and  of  headache.  Occasionally,  congestions  of  the  head  occur, 
with  alarming  dreams,  and  the  moodiness  may  increase  greatly;  in 
this  condition  three  such  patients  of  Schlager's  were  impelled  to 
attempts  at  suicide.  Schlagcr  further  draws  attention  to  the  fact 
that  in  22  cases  known  to  him  in  which  suicide  was  performed  or 
unsuccessfully  attempted  by  women,  in  eleven  of  these  the  patient 
was  at  the  climacteric  age.  He 'believes  that  the  most  important 
etiological  influence  in  the  production  of  climacteric  mental  disorder 
in  such  cases  is  the  sudden  suppression  of  menstruation.  In  the 
majority  of  these  instances,  the  mental  disorder  takes  the  form  of 
mania;  exceptionally,  however,  the  form  of  chorea  or  of  catalepsy. 

By  Tilt  the  following  forms  of  "  climacteric  insanity  "  are  dis- 
tinguished :  delirium,  mania,  hypochondriasis,  melancholia,  im- 
pulsive insanity,  and  perversion  of  the  moral  instincts.  The  same 


646  THE  SEXUAL  LIFE  OF  WOMAN. 

author  publishes  the  following  table  showing  the  age  incidence  in 
1,320  cases  of  mental  disorder  in  women,  from  which  it  appears 
that  during  the  age  of  the  menopause,  a  very  considerable  number 
of  the  cases  originate,  but  that  after  the  change  of  life  compara- 
tively few  cases  occur. 

In  these  1,320  cases  the  women  were: 

Under  15  years  of  age  in 9  instances 

Over  15  and  under  20  years  in. . 61  instances 

Over  20  and  under  25  years  in 216  instances 

Over  25  and  under  30  years  in 223  instances 

Over  30  and  under  35  years  in 217  instances 

Over  35  and  under  40  years  in 218  instances 

Over  40  and  under  45  years  in 162  instances 

Over  45  and  under  50  years  in 153  instances 

Over  50  and  under  55  years  in 122  instances 

Over  55  and  under  60  years  in 57  instances 

Over  60  and  ijnder  65  years  in 55  instances 

Over  65  and  under  70  years  in 27  instances 

Fuchs  tabulated  the  ages  of  26,300  insane  persons.  Reducing  his 
results  to  the  ratios  per  10,000,  he  obtained  the  following  results: 

Women.  Men 

At  ages  under  20 563  649 

At  ages  over  20  and  under  30 1,895  2,132 

At  ages  over  30  and  under  40 2,557  2,614 

At  ages  over  40  and  under  50 2,180  2,080 

At  ages  over  50  and  under  60 1,362  1,247 

At  ages  over  60 1,443  1,278 

According  to  Esquirol,  among  198  women  who  committed 
suicide,  there  were  77  between  the  ages  of  40  and  50  years  —  a 
number  considerably  larger  than  those  in  any  other  age-decade. 
Among  235  women  suffering  from  dementia,  a  moiety  had  first 
come  under  treatment  during  the  climacteric  age.  The  same 
author  published,  the  following  data  regarding  the  age-incidence  of 
insanity  in  the  case  of  6,713  female  patients: 

At  ages  under  20  years 348  cases 

Between  the  ages  of  20  and  25 563  cases 

Between  the  ages  of  25  and  30 727  cases 

Between  the  ages  of  30  and  40 1,607  cases 

Between  the  ages  of  40  and  50 1,479  cases 

Between  the  ages  of  50  and  60 954  cases 

At  ages  above  60  years * i ,035  cases 

Matusch  found  that  among  551  women  suffering  from  mental 
disorder,  there  were: 

At  ages    o  to  10  years 9  cases 

At  ages  10  to  20  years 73  cases 

At  ages  20  to  30  years 140  cases 

At  ages  30  to  40  years 1 14  cases 

At  ages  40  to  50  years 107  cases 

At  ages  over  50  years 38  cases 


SEXUAL  EPOCH  OF  THE  MENOPAUSE.  647 

According  to  von  Krafft-Ebing,  among  858  insane  women,  there 
were  about  60  in  whom  the  disorder  of  the  mind  appeared  to  de- 
pend upon  the  influence  of  the  climacteric,  and  in  25  of  these  there 
was  hereditary  predisposition  to  mental  disease. 

From  Kozvalewski's  interesting  work  on  the  psychoses  of  the 
climacteric,  we  quote  the  following: 

"  In  women,  the  climacteric  has  a  distinct  influence  upon  the  men- 
tal life,  and  that  influence  is  strongly  manifested  more  especially 
in  cases  in  which  during  the  age  of  puberty  mental  disturbance  had 
previously  been  noticed.  The  mental  condition  in  which  women 
approach  the  change  of  life  is  a  very  variable  one,  and  it  is  one 
largely  dependent  upon  the  circumstances  in  which  the  active  years 
of  the  sexual  life  have  been  passed.  In  some  cases,  a  woman  has 
been  so  fortunate  as  to  marry  early  and  from  affection,  and  her 
whole  married  life  has  been  passed  without  disturbance ;  her  labours 
have  not  been  exhausting,  and  her  children  have  enjoyed  good 
health;  all  have  passed  through  the  years  of  childhood  without 
untoward  incident,  and  their  development  has  been  a  happy  and  suc- 
cessful one;  in  a  word  —  everything  has  gone  well  with  her  and 
hers.  Such  a  woman  will  give  thanks  to  God  for  the  rare  felicity 
she  has  enjoyed;  and  quietly,  patiently,  and  with  understanding 
will  endure  the  inevitable  end  of  her  sexual  life.  For  such  a 
woman,  more  especially  if  she  comes  of  a  healthy  stock,  the  changes 
which  occur  in  her  reproductive  organs  at  the  epoch  of  the  climac- 
teric, need  not  entail  any  serious  shock  to  her  nervous  system,  nor 
need  they  form  the  culture  ground  for  morbid  manifestations  in 
her  nervous  system  or  in  her  mind.  Even  if  any  anomalies  in 
nervous  working  should  occur,  it  will  be  such  only  as  are  aroused 
by  the  disturbance  of  the  normal  menstrual  rhythm ;  in  such  cases, 
they  will  rarely  prove  of  a  serious  or  enduring  character. 

"  But  look,  on  the  other  hand,  upon  this  picture.  A  woman  has 
married  without  affection  and  from  pure  necessity.  Her-  husband 
has  been  a  drunkard,  and  rough  and  unfaithful.  She  has 
had  a  great  many  children,  her  labours  have  been  tedious  and  difficult 
and  accompanied  with  severe  losses  of  blood.  Some  of  the  children 
fell  sick  and  died;  those  that  survived  proved  idle,  good-for- 
nothing,  and  a  burthen.  The  family  life  is  dominated  by  quar- 
relsomeness, disorder,  and  insufficiency  of  means.  The  mother  is 
affected  with  some  chronic  disorder  of  the  reproductive  organs, 
and  is  hardly  ever  out  of  the  doctor's  hands.  After  25  or  30  years 
of  a  life  of  this  kind,  the  woman  enters  upon  the  change  of  life. 
Physically  exhausted,  weary  of  life,  never  having  known  happi- 
ness, after  an  existence  full  of  trouble  and  wretchedness,  with 
nothing  joyful  either  in  her  memories  of  the  past  or  in  her  prospect 
of  the  future  —  the  chief  hope  of  such  a  woman  is  that  her  troubles 


648  THE  SEXUAL  LIFE  OF  WOMAN. 

may  soon  end  with  her  life.  Where  the  soil  is  thus  physically  and 
mentally  exhausted,  the  development  of  a  neurosis  or  a  psychosis 
is  only  too  probable  on  the  most  trifling  exciting  cause.  Her  life 
seems  of  so  little  worth,  that  thoughts  of  suicide  are  likely  to  be 
very  near  at  hand.  Thus,  when  the  climacteric  alterations  in  the 
reproductive  organs  are  superadded,  melancholia  is  very  likely  to 
supervene.  When,  however,  the  case  is  complicated  by  hereditary 
predisposition  to  insanity,  and  by  the  occurrence  of  actual  degen- 
erative changes  in  the  central  nervous  system,  instead  of  the  passive 
depression  of  melancholia,  we  shall  rather  see  the  ideas  of  perse- 
cution of  paranoia.  As  an  actual  fact,  these  two  psychoses,  melan- 
cholia and  paranoia,  are  the  commonest  forms  of  mental  disorder 
at  this  period  of  a  woman's  life. 

"  These  are  the  two  extremes  in  woman's  mental  state  at  the 
time  when  the  physical  changes  of  the  climacteric  period  begin  in 
her  reproductive  organs.  It  will,  of  course,  be  readily  understood 
that  between  these  two  extremes  lies  a  series  of  combinations  any 
one  of  which  may  in  individual  cases  occur. 

"  The  conditions  of  life  during  earlier  years  have  thus  a  strong 
determinative  influence  in  the  production  of  mental  disorder;  and 
not  infrequently  in  these  conditions  alone  shall  we  find  the  efficient 
cause  of  the  mental  degeneration.  At  times,  the  memories  of  her 
own  life  have  in  a  woman  at  the  climacteric  age  so  serious  an 
effect,  that  these  memories  alone  constitute  the  casual  agent  of  the 
development  of  a  psychosis,  or  at  least  so  influence  the  soil  as  to 
make  it  a  suitable  culture-ground  for  the  development  of  mental 
disorder,  the  actual  exciting  cause  of  the  pathological  state  being  a 
disturbance  of  the  ordinary  menstrual  rhythm. 

"  In  considering  the  mental  condition  of  women  at  the  outset  of 
the  climacteric  period,  we  must  not  forget  those  who  are  called 
'  old  maids.'  In  their  youth  these  maidens  also  have  had  their 
ideals,  th'eir  hopes,  their  plans,  and  their  sorrows.  They  also  had  a 
natural  impulse  to  love  and  to  be  loved  in  return ;  they  hoped  to  be- 
come wives  and  mothers.  But  life  has  failed  to  fulfil  their  hopes  and 
their  wishes,  and  their  longings  have  remained  unsatisfied.  Some 
of  them  have  taken  up  their  cross  without  murmuring,  and  have 
devoted  their  talents,  their  intelligence,  and  their  love  to  the  service 
of  those  nearest  to  them.  But  others  make  an  active  protest 
against  fate  in  the  form  of  vindictive  feelings  towards  their  en- 
vironment, of  quarrelsomeness,  scandalmongering,  etc.  Here  we 
see  contrasted  the  two  principal  types  of  such  women.  On  the  one 
hand  are  those  who  devote  their  intellectual  and  spiritual  powers 
to  the  service  of  society ;  these  are  unselfish  sisters-of-mercy, 
untiring  medical  women,  invaluable  school-teachers  and  govern- 


SEXUAL  EPOCH  OF  THE  MENOPAUSE.  649 

nesses,  fanatical  political  agents,  etc.  Such  as  these  have  ceased  to 
live  for  themselves.  In  the  fullest  sense  of  the  words,  they  mortify 
the  flesh,  and  guide  their  conduct  by  lofty  moral  principles.  They 
have  killed  their  sexual  life,  and  they  remain  for  ever  virgins  — 
both  morally  and  physically.  If,  owing  to  a  pathological  inherit- 
ance, faulty  conditions  of  life,  exhausting  illnesses,  etc.,  a  psychosis 
develops,  the  hallucinations  and  delusions  from  which  they  suffer 
very  rarely  assume  a  sexual  character,  nor  are  they  of  a  degrading 
type.  The  sexual  side  of  life  seems,  in  fact,  be  they  sane  or  insane, 
to  have  undergone  complete  atrophy.  They  suffer  from  simple 
melancholia  with  stupor,  or  their  insanity  takes  a  religious  turn, 
but  very  rarely  indeed  has  it  an  erotic  character. 

"  Very  different  is  it  with  old  maids  of  the  second  type.  They 
are  dissatisfied  with  life,  irritable,  quarrelsome,  envious,  and  mali- 
cious. They  are  spiteful  and  revengeful,  gossips  and  scandal- 
mongers, boast  of  their  own  chaste  and  innocent  lives,  and  never 
forgive  any  real  or  imaginary  attempt  upon  their  spotless  virtue. 
At  the  same  time  they  never  lose  hope  for  the  future,  and  are  full 
of  imaginary  love-affairs,  in  which  they  pass  through  scenes  by 
no  means  chaste  or  innocent;  they  do  not  shrink  from  self-abuse 
and  the  abnormal  gratification  of  the  sexual  needs,  in  which  the 
lacking  partner  in  the  sexual  act  is  supplied  by  the  imagination. 
Under  the  influence  f  of  such  abnormal  conditions  of  life,  these 
women  frequently  become  affected  by  nervous  disorders;  migraine, 
neuralgia,  cephalalgia,  nervous  depression,  rachialgia,  debility, 
anaemia,  diseases  of  the  reproductive  organs,  etc.  Thus,  when 
they  enter  the  climacteric  age,  the  soil  is  fully  prepared  for  the 
development  of  mental  disorder,  which  in  such  individuals  is  often 
characterized  by  hallucinations  of  sexual  sensation  and  perception, 
erotic  visual  and  auditory  hallucinations,  delusions  of  similar  char- 
acter, increased  sexual  irritability,  a  search  for  abnormal  means 
of  sexual  gratification,  a  propensity  to  obscene  speech  and  conduct, 
etc. 

"  Mental  disorder  is  so  common  during  the  climacteric  period, 
that  the  term  '  climacteric  insanity  '  has  now  become  established 
in  the  literature  of  mental  alienation.  In  almost  all  the  textbooks 
of  the  subject  we  find  an  allusion  to  this  form  of  mental  disease, 
but  there  is  no  real  ground  for  Maudsley's  assumption 
that  there  is  a  climacteric  insanity  sui  generis.  At  the  climac- 
teric, very  various  forms  of  mental  disorder  may  occur  —  paranoia, 
melancholia,  and  mania ;  the  only  common  feature  in  the  attacks, 
owing  to  which  they  are  classed  as  '  climacteric  insanity,'  being 
the  fact  that  the  final  determining  cause  in  each  case  is  the  onset  of 
the  change  of  life.  In  fact,  this  period  is  not  without  influence 


650  THE  SEXUAL  LIFE  OF  WOMAN. 

upon  the  manifestation  of  the  disease  —  its  stamp  is  imprinted  upon 
the  clinical  picture,  it  endues  the  disease  with  certain  characteristic 
features  —  but  still,  the  peculiarities  common,  to  the  cases  of  mental 
disorder  occurring  at  this  time  of  life  in  women  are  not  so  great 
as  to  justify  us  in  describing  them  as  a  separate  variety  of  psy- 
chosis." 

According  to  Kou>aleivski,  this  so-called  climacteric  insanity  is 
met  with  in  two  principal  forms :  in  many  cases  the  mental  dis- 
order recurs  in  periodic  paroxysms,  associated  either  with  the  com- 
mencement of  the  menstrual  flow,  or  having  the  periodicity  of 
menstruation  after  the  flow  has  already  ceased  to  appear;  in  the 
other  class  of  cases  the  psychosis  has  no  direct  connexion  with 
menstruation,  and  is  dependent  upon  the  joint  influence  of  all  the 
manifestations  of  the  climacteric  period.  Cases  belonging  to  the 
former  class  have  been  distinguished  by  Bartel  as  "  climacteric 
pseudomenstrual  insanity." 

The  psychoses  dependent  upon  the  climacteric  influences  may, 
according  to  Koivaleivski,  appear  in  almost  all  the  known  forms 
of  mental  disorder :  precordial  anxiety,  melancholia,  mania,  amentia, 
paranoia,  etc. ;  and  although  they  exhibit  no  features  which  are 
absolutely  characteristic,  or  which,  as  already  said,  enable  us  to 
distinguish  a  specific  "  climacteric  insanity,"  yet  they  all  bear  a 
common  imprint  by  means  of  which  we  are  enabled  to  detect  in 
their  causation  the  influence  of  this  critical  period  of  life.  Thus, 
precordial  anxiety  occurs  in  paroxyms  having  a  more  or  less  regu- 
lar periodicity,  corresponding  with  that  of  the  expected  menstrua- 
tion. The  same  feature  is  observable  in  the  periodic  exacerbations 
of  hysterical  and  epileptic  paroxysms.  Often,  also,  there  occur  at 
this  time  sudden  changes  in  the  emotional  disposition  and  in  the 
character,  in  one  direction  or  the  other,  without  the  development 
of  actual  melancholia  or  mania.  The  melancholia  of  the  climacteric 
period  occurs  chiefly  in  married  women,  more  especially  in  those 
whose  circumstances  are  unhappy;  and  it  is  often  manifested  by 
attempts  at  suicide. 

Mania  is  comparatively  rare  at  the  climacteric  period;  when  it 
does  occur,  it  commonly  assumes  a  sexual  form  —  sexual  impulses, 
hallucinations,  and  delusions,  and  obscene  conduct.  Such  mani- 
festations are  seen  most  often  in  widows,  in  "  old  maids  "  whose 
morals  are  not  above  reproach,  and,  speaking  generally,  in  those 
whose  sexual  needs  have  remained  partially  or  completely  un- 
gratified,  and  in  those  who  have  greatly  erred  in  the  conduct  of 
this  side  of  life.  Amentia  also  occurs  at  this  time  of  life ;  rarely 
in  maniacal  form,  more  frequently  in  association  with  menstruation 
as  a  periodic  psychosis,  or  as  a  continuous  disorder  of  mind  with 


SEXUAL  EPOCH  OF  THE  MENOPAUSE.  651 

exacerbations  corresponding  to  the  menstrual  periods ;  it  is  often 
characterized  by  pronounced  eroticism. 

Much  more  frequent  during  the  climacteric  period  is  the  occur- 
rence of  paranoia,  as  Kowalewski  rightly  insists.  It  is  most  often 
met  with  in  "  old  maids  "  with  psychopathic  predisposition.  The 
imagination  of  such  individuals  is  always  concentrated  upon  men; 
they  imagine  that  men  in  general,  but  more  particularly  certain  indi- 
viduals of  the  opposite  sex,  are  continually  regarding  them,  making 
eyes  at  them,  making  signs  to  them,  in  some  way  or  other  striving 
to  attract  their  attention.  The  most  ordinary  and  invariable  forms 
of  polite  intercourse  are  regarded  by  these  women,  whose  powers 
of  observation  are  morbidly  stimulated,  as  being  indications  of  a 
special  "  attention  "  paid  to  themselves.  They  persecute  these  men 
with  their  own  attentions,  and  imagine  that  it  is  the  men  who  are 
persecuting  them.  Often  this  morbid  mental  state  is  associated 
with  sexual  malpractices,  masturbation,  etc.  Not  rarely,  such  de- 
generates are  affected  with  lascivious  dreams.  Often  they  experi- 
ence hallucinations  of  sexual  perception  in  the  form  of  supposed 
assaults  on  their  virginity.  All  these  states  are  apt  speedily  to 
develop  into  a  condition  of  general  suspiciousness  and  ideas  of 
persecution.  The  ideas  of  persecution  assume  a  peculiar  form, 
one  especially  characteristic  of  the  climacteric  period.  The  patients 
believe  that  a  man,  often  personally  unknown  to  them,  and  perhaps 
living  in  another  town,  enters  into  spiritual  and  bodily  intercourse 
with  them.  These  relations  are  supposed  to  be  effected  in  most 
cases  by  means  of  spiritualism,  hypnotism,  or  electricity.  The 
patient  importunes  the  man  in  question  with  letters,  supposes  her- 
self to  be  legally  united  with  him,  and  not  infrequently  wishes  to 
give  him  the  pleasure  of  paying  her  bills  and  providing  her  with 
money.  It  is  a  very  common  occurrence  for  a  Catholic  priest  to  be 
worried  by  such  a  woman,  her  delusion  being  grounded  upon  the 
fact  that  the  priest  is  supposed  to  assume  an  exceptionally  intimate 
spiritual  relationship  with  members  of  his  flock.  The  patient  with 
ideas  of  persecution  often  herself  becomes  an  actual  persecutor, 
not  only  pestering  her  victim  with  innumerable  letters,  but  in  her 
jealousy  making  "  scenes  "  whenever  she  can  encounter  him,  and 
sometimes  giving  rise  to  serious  scandal.  With  such  a  mental  state 
we  often  see  associated  sexual  hallucinations  and  delusions;  the 
patient  believes  herself  to  be  pregnant,  imagines  herself  to  have 
been  violated,  or  to  be  living  in  carnal  intercourse  with  a  man  — 
some  one,  it  may  be,  with  whom  she  is  not  even  acquainted. 
Medical  men  are  especially  apt  to  surfer  from  the  accusations  of 
such  women,  whom  they  may  have  examined  in  private  in  entire 
ignorance  of  the  patient's  mental  condition.  Frequently,  such  ideas 


LlL 
COLLIE  lilE-  01 


652  THE  SEXUAL  LIFE  OF  WOMAN. 

'of  sexual  persecution  are  associated  with  paroxysms  of  violent 
nymphomania,  and  in  this  way  also  the  unwary  physician  may 
find  himself  placed  in  an  extremely  unpleasant  position.  It  occa- 
sionally happens  in  such  patients  that  abnormalities  of  the  sexual 
instinct  arise,  and  they  begin  to  feel  desire  towards  individuals  of 
their  own  sex. 

Such  delusions  of  persecution  by  means  of  hypnotism,  spiritu- 
alism, the  telephone,  etc.,  in  association  with  sexual  delusions  and 
nymphomania,  are  so  frequent  during  the  climacteric  period,  that 
they  may  be  regarded  as  preeminently  constituting  climacteric  in- 
sanity. Frequently  some  old  hysterical  state  underlies  this  form 
of  mental  disorder. 

Thus  these  peculiar  manifestations  of  eroticism  must  be  regarded 
as  the  distinctive  characteristics  of  climacteric  insanity  and  more 
particularly  of  climacteric  paranoia.  A  second  characteristic  of 
climacteric  insanity  is,  according  to  Garat,  the  marked  development 
of  jealous  emotions  and  delusions. 

In  addition  to  these  fully  developed  psychoses,  there  occur  in 
degenerates  at  the  climacteric  age  paroxysms  of  impulsive  insanity 
in  the  form  of  dipsomania,  kleptomania,  pyromania ;  exhibitionism ; 
irresistible  impulse  to  suicide,  homicide,  infanticide,  etc.  Such 
paroxysmal  impulsive  manifestations  are,  according  to  Koivalcwski, 
commonly  associated  with  menstrual  disturbances ;  they  occur  most 
frequently  at  the  due  dates  of  menstruation  when  the  flow  fails  to 
appear. 

One  hundred  and  sixty-nine  cases  of  climacteric  psychosis  were 
classified  by  Matusch  as  follows : 

Melancholia j6  cases 

Mania  2  cases 

Melancholia  passing  on  into  paranoia 28  cases 

Melancholia  passing  on  into  secondary  dementia 17  cases 

Paranoia 43  cases 

Neurasthenia  during  the  climacteric  period  followed  by  mental 

disorder  19  cases 

Neurasthenia  prior  to  the  climacteric  period,  followed  by  mental 

disorder  during  the  climacteric  period 10  cases 

Apoplexy,  cerebral  abscess,  dementia 6  cases 

Epilepsy  2  cases 

Alternating  insanity  3  cases 

Paralytic  dementia  5  cases 

Von  Krafft-Ebing  classified  60  cases  of  climacteric  psychosis  as 
follows : 

Melancholia  4  cases 

Alternating  insanity I  case 

Acute   delirium    I  case 

Primary  insanity : 

a.  With    primordial    delirium 36  cases 

b.  Paralytic  dementia    •.  12  cases 


SEXUAL  EPOCH  OF  THE  MENOPAUSE.  653 

The  prognosis  in  cases  of  climacteric  psychosis  is  regarded  by 
Kowalcwski  as  unfavourable;  unfavourable  vital  conditions  are 
associated  with  retrogressive  metamorphosis  of  the  tissues,  hence 
mental  disorder  arising  at  this  time  of  life  is  hardly  less  serious 
than  that  due  to  actual  degeneration  of  cerebral  tissues.  Indeed, 
according  to  Schiller  there  is  during  the  climacteric  period  an 
especial  danger  of  the  development  of  atrophic  cerebral  processes 
(Encephalitis  atheromatosa)  with  apoplectic  and  epileptic  seizures. 
Schlagcr  also  regards  the  prognosis  of  climacteric  insanity  as  un- 
favourable ;  but  Mcrson,  on  the  other  hand,  observed  among  women 
suffering  from  climacteric  psychoses  a  recovery  rate  of  over  50$. 
On  previously  existent  psychoses  in  women,  the  onset  of  the 
climacteric  exercises  in  most  cases  an  unfavourable  influence,  a"nd 
very  exceptionally  only  at  this  time  do  we  observe  the  cure  or  re- 
mission of  a  chronic  mental  disorder  to  occur.  Koii'alczvski  has 
seen  cases  of  chronic  mania  in  which  a  cure  was  obtained  at  the 
climacteric  period ;  a  somewhat  excessive  excitability  and  inclina- 
tion to  violence  remained,  however,  as  vestiges  of  the  former 
insanity.  Matusch,  keeping  under  observation  60  women  af- 
fected with  chronic  mental  disorder  as  they  attained  the  climacteric 
period,  noticed  that  in  14  instances  the  mental  condition 
changed  for  the  worse  at  this  period,  whilst  in  13  the  char- 
acter of  the  mental  disease  underwent  a  change,  excitement  giving 
place  to  apathy  and  dementia.  Gricsingcr  had  earlier  pointed  out 
that  at  the  time  of  the  cessation  of  menstruation  there  would 
occasionally  occur  amelioration,  and  even  cure,  of  a  previously 
existing  chronic  mental  disorder;  more  often,  however,  the  influ- 
ence of  the  menopause  was  an  unfavourable  one,  a  hitherto  change- 
able and  irritative  form  of  mental  disease  becoming  transformed 
into  chronic  insanity  with  inalterable  delusions,  or  into  dementia. 
The  course  of  mental  disorder,  such  as  melancholia,  first  making 
its  appearance  at  the  climacteric  epoch,  was  also  regarded  by 
Griesinger  as  likely  to  be  unfavourable. 

HYGIENE  DURING  THE  MENOPAUSE. 

During  the  critical  years  of  a  woman's  life  it  is  the  aim  of 
hygiene  to  employ  all  the  means  available  to  counteract  tne 
changes  in  the  circulation  of  the  blood,  the  disturbances  in  the 
working  of  the  nervous  system,  and  the  nutritive  disorders,  which 
are  in  various  ways  dependent  upon  the  changes  occurring  in  the 
reproductive  organs  during  the  climacteric  period ;  its  endeavour 
should  be  so  to  regulate  the  conduct  of  life  in  this  epoch  that  the 
important  episode  of  the  gradual  decline  and  ultimate  extinction 


654  THE  SEXUAL  LIFE  OF  WOMAN. 

of  sexual  productivity  shall  be  effected  with  as  few  local  troubles 
as  possible,  and  as  slight  variations  in  the  general  condition. 

By  means  of  baths  of  various  temperature,  duration,  mode  of 
application,  and  composition,  and  by  other  selected  hydrotherapeutic 
procedures,  we  are  enabled  during  the  disturbances  of  the  meno- 
pause to  exert  upon  the  skin  a  powerful  derivative  influence,  and 
in  this  way  to  diminish  the  passive  hyperaemia  of  the  uterus  and 
the  uterine  annexa ;  by  the  same  means  we  can  exercise  a  sedative 
influence  on  the  peripheral  nerves  and  thus  further  upon  the  entire 
nervous  system,  whenever  such  measures  are  called  for  by  the 
manifold  indications  of  increased  irritability;  further,  by  the  use 
of  baths  we  can  influence  the  circulation  of  the  blood,  we  can 
increase  the  sudatory  activity  of  the  skin,  and  in  various  additional 
ways  we  can  affect  heat  production  and  metabolism,  thus  modifying 
the  processes  occurring  in  the  reproductive  organs,  making  the  con- 
ditions favourable  for  the  absorption  of  exudations,  and  promoting 
a  healthy  tissue-change  in  the  mucous  membrane  of  the  genital 
passages. 

In  climacteric  women,  the  most  usual  indications  are  for  the 
employment  of  water-baths  at  an  indifferent  temperature,  35  to 
37°  C.  (95  to  98°  F.),  of  moderate  duration,  15  to  20  minutes, 
the  bath  being  one  of  simple  immersion,  not  of  douche  or  affusion, 
and  the  temperature  being  kept  constant  by  continuous  inflow  of 
a  sufficient  quantity  of  hot  water.  Such  baths  as  these  promote  in 
a  mild  but  continuously  efficient  manner  the  functions  of  the  skin 
—  so  important  during  the  climacteric  epoch ;  and  they  lessen  the 
almost  constant  tendency  to  perspirations  and  to  the  development 
of  diseases  of  the  skin  (the  commonest  of  which  is  climacteric 
eczema).  The  moderate  degree  of  thermic  stimulus  exercised  by 
baths  at  such  an  indifferent  temperature  leads  them  to  have  an 
equable  sedative  effect  upon  the  nervous  system,  which  is  probably 
dependent  upon  an  influence  exerted  through  the  intermediation 
of  the  sensory  nerve-terminals  in  the  skin ;  and  this  is  most  bene- 
ficial in  lessening  the  increased  general  irritability,  both  sponta- 
neous and  reflex,  so  commonly  manifested  by  the  nervous  system  at 
the  climacteric  period.  In  women  at  this  time  of  life,  such  baths 
are  most  useful  in  allaying  the  common  cutaneous  hyperaesthesias 
and  neuralgias,  and  have  a  reflex  influence  also  upon  the  visceral 
neuralgias  and  psychical  hyperaesthesias. 

In  climacteric  women  suffering  from  abnormal  sensitiveness  to 
sensory  impressions,  to  strong  light  and  loud  noises,  or  from  pain- 
ful sensations  in  the  most  diverse  nerve  areas;  in  those  subject  to 
palpitation  of  the  heart  after  some  trivial  exciting  cause ;  in  those 
affected  with  cramp-like  seizures  in  the  pharynx,  the  oesophagus, 


SEXUAL  EPOCH  OF  THE  MENOPAUSE.  655 

the  stomach,  and  the  intestinal  tract;  in  women  with  distressing 
sensations  of  itching  and  burning  in  the  reproductive  organs,  or  in 
those  in  whom  there  is  a  great  increase  in  the  intensity  of  the 
sexual  impulse  —  in  all  these  common  disturbances  of  the  meno- 
pause, by  the  daily  use  of  such  immersion  baths  of  water  at  an 
indifferent  temperature,  best  taken  immediately  before  retiring  to 
rest,  we  shall  often  succeed  in  inducing  both  local  and  general 
repose,  in  diminishing  the  spontaneous  and  reflex  irritability  of  the 
nervous  system,  and  in  inducing  quiet  and  restorative  sleep. 

In  other  cases  of  disturbances  of  health  during  the  climacteric 
period,  however,  more  benefit  may  be  derived  from  hot  immersion 
baths,  taken  at  a  temperature  well  above  blood  heat,  (37°  C. — 
98.4°  F.)  and  lasting  longer  than  the  warm  baths  just  described. 
These  are  indicated  when  we  wish  to  increase  the  activity  of  the 
circulation  through  the  skin,  to  give  rise  to  hyperaemia  of  the 
superficial  structures  of  the  body,  to  stimulate  powerfully  the 
cutaneous  nerves,  to  promote  cutaneous  perspiration  —  in  short,  to 
exercise  a  powerful  derivative  effect,  to  promote  resorption,  and 
to  accelerate  the  general  processes  of  tissue-change.  This  method 
of  treatment  is  suitable  for  cases  in  which  at  the  commencement 
of  the  menopause  there  are  already  pathological  conditions  of  the 
reproductive  organs,  the  morbid  states  being  now  aggravated  by 
the  processes  of  the  climacteric  —  such  conditions  are  metritis  and 
endometritis,  chronic  inflammations  of  the  intra-pelvic  connective 
tissue  and  of  the  pelvic  peritoneum;  and  one  of  the  first  aims  of 
treatment  must  be  to  promote  the  softening  and  subsequent  absorp- 
tion of  these  inflammatory  products.  Again,  in  cases  in  which  the 
climacteric  troubles,  dependent  in  part  on  increased  general  arterial 
blood-pressure,  manifest  themselves  chiefly  in  the  form  of  active 
congestions,  fugitive  heats,  vertigo,  etc.,  the  employment  of  hot 
baths  is  likely  to  be  most  useful  by  leading  to  a  notable  enlargement 
of  the  cutaneous  capillary  blood-vessels  and  consequent  lowering 
of  arterial  blood-pressure.  Further,  in  cases  of  compensatory 
fluxes,  periodic  diarrhoeas,  periodic  leucorrhoea,  following  the  sup- 
pression of  the  menstrual  flow,  in  cases  of  vicarious  haemorrhage 
(especially  periodic  epistaxis  and  periodical  haemorrhoidal  bleed- 
ings), the  use  of  hot  baths  is  often  competent  to  restore  the  func- 
tional activity  of  the  ovaries  when  this  has  undergone  premature 
cessation.  In  addition,  their  use  assists  us  in  our  endeavours  to 
counteract  excessive  obesity  and  gouty  disorders,  diseases  which 
tend  especially  to  make  their  appearance  in  women  at  the  epoch 
of  the  menopause,  disorders  of  metabolism  intimately  associated 
with  the  disturbances  of  the  uterine  and  ovarian  functions  charac- 
teristic of  the  change  of  life. 


656  THE  SEXUAL  LIFE  OF  WOMAN. 

In  all  the  conditions  just  enumerated,  if  we  desire  a  still  more 
powerful  influence  than  that  exerted  by  ordinary  hot  baths,  it  is 
in  our  power  to  employ  hot  mineral  water  baths,  by  means  of 
which  a  chemical,  and  perhaps  also  an  electrical,  stimulation  of  the 
cutaneous  nerves  is  superadded  to  the  simple  thermic  stimulus 
conveyed  by  the  hot  water.  The  different  effects  of  the  various 
mineral  baths  depends  upon  both  the  saline  and  the  gaseous  con- 
stituents of  the  different  springs,  and  upon  the  peculiar  physical 
properties  of  the  mineral  waters. 

Sudorific  baths  are  of  various  kinds.  Some,  Russian  baths,  con- 
sist of  hot  air  saturated  with  moisture;  others,  Roman-Irish  baths, 
consist  of  dry  hot  air;  the  most  recent  of  all  are  the  electric  light 
baths,  in  which  the  radiant  heat  of  electric  lamps  is  utilized.  But 
owing  to  the  great  increase  in  the  body  temperature  which  they 
cause,  with  consequent  increased  frequency  of  pulse  and  breathing, 
and  still  more  on  account  of  the  rapid  and  extensive  increase  in 
blood-pressure  to  which  they  give  rise,  these  powerful  sudorific 
baths  are  rarely  suitable  for  climacteric  women,  and  if  used  at  all 
in  such  cases  the  greatest  caution  must  be  employed.  Their  use  is 
indicated  only  in  women  in  whom  at  the  time  of  the  menopause 
the  rapid  onset  of  obesity  has  given  rise  to  serious  troubles,  but  in 
whom  the  heart  is  perfectly  sound  and  in  wham  the  blood  vessels 
show  no  trace  of  sclerosis. 

Far  less  often  than  warm  or  hot  baths,  or  mineral  water  baths, 
are  cold  baths  employed  during  the  climacteric  period,  for  baths 
at  a  temperature  considerably  below  the  indifferent  point,  and  other 
hydrotherapeutic  procedures  in  which  cold  water  is  used,  stimulate 
the  nervous  system  so  powerfully  and  give  rise  to  so  great  an 
increase  in  blood-pressure,  that  their  use  is  generally  to  be  avoided 
in  climacteric  women,  since  indeed  it  is  apt  to  entail  serious  dangers 
both  physical  and  mental.  Immersion  baths,  plunge  baths,  or 
sponge  baths,  in  which  the  water  employed  is  at  a  temperature  of 
18°  C.  (64°  F.)  or  less,  are  contraindicated,  for  they  act  too  ener- 
getically, abstract  heat  too  powerfully,  to  be  safely  employed  at 
this  epoch  of  life.  If  we  seek  by  means  of  hydrotherapeutic 
measures  to  counteract  states  of  congestion  at  the  time  of  the 
menopause,  and  at  the  same  time  to  bring  about  a  general  invigora- 
tion  of  the  patient's  nervous  system,  immersion  baths  the  water 
of  which  is  not  below  20°  C.  (68°  F.),  and  lasting  from  five  to 
fifteen  minutes,  would  appear  to  be  indicated.  In  the  majority 
of  such  cases,  however,  a  somewhat  higher  temperature  is  prefera- 
ble, from  26  to  28°  C.  (79  to  82°  F.),  the  patient  lying  at  full 
length  in  the  bath,  immersed  to  above  the  shoulders,  and  the  water 
not  being  agitated  except  by  a  moderate  nibbing  of  the  surface 
of  the  body  whilst  the  patient  is  in  the  bath.  When,  however,  the 


SEXUAL  EPOCH  OF  THE  MENOPAUSE.  657 

patient  sits  in  the  bath,  the  water  covering  only  the  lower  half 
of  the  body  as  high  as  the  navel,  a  somewhat  lower  temperature  is 
permissible,  20  to  25°  C.  (68  to  77°  F.)  ;  but  the  duration  should 
not  exceed  five  minutes,  moderate  mechanical  manipulations  being 
carried  out  meanwhile ;  such  baths  appear  to  reduce  nervous  irrita- 
bility and  to  have  a  sedative  effect  in  the  manifold  nervous  disturb- 
ances of  the  climacteric  period.  Sitz-baths,  again,  of  a  longer  dura- 
tion, twenty  to  sixty  minutes,  the  water  reaching  only  to  the  navel, 
and  being  at  a  temperature  varying  from  16  to  25°  C.  (60  to 
77°  F.),  are  useful  in  relieving  chronic  inflammatory  states  of  the 
reproductive  organs  and  the  associated  erotic  states  and  abdominal 
pain  and  irritability.  Colder  stiz-baths,  even  of  brief  duration, 
should,  on  the  other  hand,  be  avoided.  Similarly,  a  shower-bath 
of  water  at  a  temperature  of  18  to  24°  C.  (64  to  75°  F.),  lasting 
one  to  two  minutes,  and  the  water  falling  only  from  a  very  slight 
elevation  above  the  head,  have  a  valuable  sedative  action;  but,  on 
the  other  hand,  a  colder  shower-bath,  of  water  falling  from  a 
greater  height,  has  an  exciting  action,  and  is  to  be  avoided  at  this 
time  of  life.  When  there  are  severe  congestive  symptoms,  fric- 
tion of  the  hands  and  feet  for  a  short  time  with  water  at  a  tem- 
perature from  12  to  17°  C.  (54  to  63°  F.),  followed  by  a  quarter 
of  an  hour's  rest  in  bed,  may  be  recommended ;  also  immersion  of 
the  feet  for  a  minute  in  water  at  a  temperature  of  10°  C.  (50°  F.), 
the  feet  being  vigorously  rubbed  the  while,  followed  by  a  walk  in 
the  open  for  five  or  ten  minutes.  In  cases  of  sleeplessness  at  the 
menopause  due  to  congestion,  a  useful  method  is  to  dip  the  feet 
for  twenty  or  thirty  seconds  in  water  at  a  temperature  of  8  to 
10°  C.  (46  to  50°  F.),  the  feet  being  briskly  rubbed  whilst  in 
the  water,  or  moved  rapidly  up  and  down  with  treading  movements ; 
after  withdrawal,  they  are  quickly  dried,  and  the  patient  imme- 
diately goes  to  bed.  Another  useful  mild  soporific  measure  is  to 
apply  before  going  to  bed  bandages  wrung  out  of  cold  water ;  these 
reach  from  the  foot  to  the  knee,  and  are  left  on  for  the  whole 
night.  In  cases  of  climacteric  menorrhagia,  my  vaginal  refrig- 
erator should  be  used  for  the  direct  application  of  cold  to  the  re- 
productive organs ;  this  is  a  cylindrical  apparatus  introduced  into 
the  vagina,  cold  water  flows  through  the  interior  of  the  apparatus 
without  wetting  the  vaginal  mucous  membrane.  This  cooling  ap- 
paratus is  useful  also  in  troublesome  cases  of  genital  pruritus ;  cold 
douches  to  the  vulva  for  one  or  two  minutes  at  a  time  are  likewise 
valuable  in  the  relief  of  this  affection. 

For  climacteric  women,  cold  sea-bathing  is  as  little  to  be  recom- 
mended as  other  cold  hydrotherapeutic  measures,  owing  to  its 
powerful  refrigerative  effect,  and  the  great  mechanical  influence 

42 


658  THE  SEXUAL,  LIFE  OF  WOMAN. 

of  the  moving  water  in  the  waves.  But  in  certain  cases,  in  which 
sea-air  is  likely  to  be  beneficial,  lukewarm  sea-baths  may  also  be 
recommended;  their  effect  is  similar  to  that  of  weak  brine-baths 
at  a  similar  temperature. 

During  the  climacteric  period,  especial  attention  must  be  paid  to 
the  care  of  the  skin.  Owing  to  the  extreme  sensitiveness  of  the 
skin  at  this  time  of  life  to  outward  noxious  influences,  it  is  neces- 
sary to  exercise  great  care  to  dry  the  skin  v.ery  thoroughly  after 
ordinary"  ablutions  of  the  face  and  hands ;  irritating  soaps  should 
be  avoided,  and  a  bland  powder  should  be  applied  after  drying. 
During  the  earlier  part  of  the  climacteric  period,  when  menstruation 
has  already  ceased,  and  senile  changes  in  the  skin  with  atrophy  of 
the  subcutaneous  tissues  have  commenced,  the  extreme  dryness  of 
the  skin  may  be  relieved  by  lukewarm  baths  with  wet  packs  to 
follow ;  after  the  bath,  the  woman  is  enveloped  in  moist  linen  cloths 
and  then  covered  over  all  with  a  blanket.  When  the  skin  chaps 
readily,  inunction  of  lanolin  ointment  will  be  found  useful. 

Cleanliness  of  the  genital  organs,  at  all  times  of  importance,  is 
doubly  so  during  the  climacteric  period,  for  the  reason  that  neglect 
in  this  respect  is  apt  to  lead  to  the  onset  of  genital  pruritus.  Not 
only  after  defaecation,  but  after  each  act  of  urination  as  well,  the 
external  genital  organs  and  the  anus  should  be  carefully  washed 
over  with  a  pad  of  clean  absorbent  wool  moistened  with  lukewarm 
water.  After  the  washing,  either  powder  or  ointment  should  be 
applied,  the  former  in  cases  in  which  the  skin  of  the  parts  is  usually 
damp  from  a  natural  tendency  to  excessive  secretion,  the  latter  in 
cases  in  which  the  skin  is  dry  and  tends  to  crack. 

Bodily  exercise,  carefully  selected  and  regulated  to  suit  the  in- 
dividuality of  each  patient,  is  a  powerful  means  of  relieving  the 
disturbances  of  the  menopause.  Regular  and  methodical  bodily 
exercise  —  to  which  it  must  be  remembered,  women  at  the  climac- 
teric period  commonly  feel  considerable  aversion  —  manifests  its 
good  effects  in  the  form  of  improvement  in  the  nutritive  conditions 
and  functional  activity  of  all  the  organs,  and  increased  activity  of 
all  metabolic  changes,  which  are  commonly  sluggish  in  women  at 
the  change  of  life.  Moreover,  muscular  exercise,  by  increasing  the 
volume  of  blood  passing  through  the  muscles,  -has  a  beneficial 
derivative  influence  in  diminishing  the  congestion  of  the  brain 
and  the  other  troublesome  congestive  symptoms  which  are  liable 
to  occur  in  women  during  the  menopause.  Again,  in  cases  of 
excessive  obesity  such  as  so  commonly  occur  in  women  at  the 
change  of  life,  the  increased  combustion  of  fat  promoted  by  regular 
muscular  exercise,  cannot  fail  to  have  a  beneficial  effect.  Finally, 
suitably  selected  muscular  exercise  has  a  favourable  influence  also 


SEXUAL,  EPOCH  OF  THE  MENOPAUSE.  659 

upon  the  nervous  system,  the  functional  activity  of  which  it  facili- 
tates, while  at  the  same  time  it  strengthens  the  powers  of  the  will. 

It  is  therefore  of  importance  that  at  the  time  of  the  menopause 
women  should  continue  to  undertake  appropriate  active  exercise, 
regular  daily  walks,  which  should  include  walking  up  a  moderate 
incline.  As  a  preparation  for  such  exercise  (in  persons  hitherto 
unaccustomed  to  walk  much),  or  in  bad  weather,  or,  again,  when 
there  are  special  reasons  against  open  air  exercise,  and  finally  as 
a  supplementary  exercise  to  walking,  gymnastics  and  massage  may 
be  employed.  Such  gymnastic  procedures  are  to  be  chosen  as  will 
serve  to  deplete  the  vessels  of  the  head,  will  have  a  favourable 
influence  upon  the  portal  circulation,  and  will  withdraw  the  blood- 
stream from  the  pelvic  organs;  such  are,  in  addition  to  general 
gymnastic  exercises,  methodical  deep  breathing,  methodical  exercise 
of  the  abdominal  muscles,  exercises  involving  the  extensors  of  the 
back  and  the  abductors  and  external  rotators  of  the  thigh,  and 
exercises  of  the  extremities.  Various  gymnastic  apparatus  may  be 
employed  with  advantage,  and  more  especially  those  in  which  the 
various  muscular  movements  are  effected  against  a  resistance.  But 
in  all  cases  extreme  care  must  be  taken  to  avoid  over-fatigue  and 
over-exertion.  A  graduated  form  of  bodily  exercise  combined  with 
passive  gymnastics,  suitable  for  climacteric  women,  is  massage,  in 
which  by  mechanical  stimulation,  by  pressure  and  friction  of  the 
whole  body  or  of  certain  parts,  the  nutrition  of  the  muscles  is 
favourably  influenced,  and  'the  activity  of  the  general  circulation 
is  increased.  In  the  use  of  massage  also,  in  climacteric  women,  all 
undue  excitation  of  the  nervous  system  is  to  be  carefully  avoided, 
a  mild  form  of  this  powerful  agent  must  alone  be  employed ;  gentle 
stretching  and  rubbing  of  the  skin  of  the  lower  extremities,  the 
back,  and  the  abdomen,  followed  by  gentle  kneading  of  the  muscles. 
Massage  of  the  internal  reproductive  organs  (the  method  of  Thure 
Brandt),  in  view  of  the  common  tendency  to  sexual  excitability  in 
women  at  the  climacteric,  is  mentioned  only  to  be  prohibited.  For 
the  same  reason,  and  also  on  account  of  the  frequency  with  which 
at  the  time  of  the  menopause  women  suffer  from  tachycardia  and 
from  other  disorders  of  the  heart,  bicycling  is  in  most  cases  an 
unsuitable  exercise  at  this  time  of  life. 

A  matter  of  great  importance  is  the  regulation  of  the  diet  of 
women  during  this  phase  of  life,  the  aim  of  such  regulation  being 
one  which  the  older  physicians  sought  to  fulfil  by  means  of  vene- 
section and  wet  cupping,  namely,  to  overcome  the  abnormality  in 
the  constitution  of  the  blood  which  arises  from  the  cessation  of 
the  internal  secretion  of  the  ovaries,  and  further  to  relieve  the 
symptom-complex  of  abdominal  plethora  and  the  various  passive 
hyperaemias  and  collateral  congestions;  and  in  addition  to  subdue 


660  THE  SEXUAL  LIFE  OF  WOMAN. 

the  great  general  nervous  irritability,  the  sensibility  to  external 
stimuli,  the  inclination  to  excessive  reflex  manifestations,  charac- 
teristic in  women  during-  the  climacteric  period. 

The  diet  must  be  regulated  in  respect  both  of  quality  and  quan- 
tity, and  it  is  obvious  that  the  regulation  must  be  thoughtfully 
adapted  to  the  needs  of  each  individual  case. 

As  regards  quantity,  the  main  general  principle  of  dietetics  for 
climacteric  women  is  that  over-nutrition  is  to  be  avoided,  that  the 
quantity  .of  nutriment  must  be  reduced  to  the  absolute  minimum 
necessary  to  supply  the  needs  of  the  tissues.  In  view  of  the  fact 
that  we  are  concerned  with  women  at  a  comparatively  advanced 
period  of  life,  whose  physical  labours  are  not  as  a  rule  exhaust- 
ing, that  quantity  of  food  will  usually  be  sufficient  which  is  com- 
petent to  furnish  35  to  40  calories  per  body-kilogram  per  diem. 
If  we  assume  that  the  mean  body-weight  of  a  woman  as  the 
climacteric  age  is  60  kilograms,  the  heat-equivalent  of  the  food  re- 
quired daily  by  such  a  woman  may  be  estimated  at  2,100  to  2,400 
calories.  This  will  be  approximately  supplied  by  a  diet  consist- 
ing of  loo  grams  albumen,  60  grams  fat,  and^5o  grams  carbohy- 
drate. The  customary  preference  for  a  large  amount  of  nitro- 
genous food  is,  however,  not  dependent  upon  physiological  re- 
quirements, and  provided  that  the  needful  minimum  of  albumen 
is  supplied  (about  1.5  gram  per  body-kilogram  per  diem),  the 
requisite  number  of  calories  may  be  furnished  by  very  various 
combinations  of  the  different  nutritive  elements. 

The  general  principles  of  the  qualitative  regulation  of  the  diet 
of  climacteric  women  are:  first  that  after  the  necessary  minimum 
of  albumen  has  been  supplied,  there  shall  be  added  an  amount  of 
carbohydrate  and  of  fat  varying  in  relative  proportions  and  quanti- 
ties according  to  the  physiological  requirements  of  the  individual, 
but  taken  together  sufficient  to  supply  the  necessary  heat-equiva- 
lent; secondly,  that  there  should  be  an  abundant  consumption  of 
water;  thirdly,  that  stimulating  dietetic  adjuvants  should  as  far  as 
possible  be  avoided. 

The  nitrogenous  equilibrium  of  the  body  may  be  maintained 
either  by  animal  or  by  vegetable  proteids ;  in  the  case  of  the  former 
(animal  albumens),  the  climacteric  woman  should  avoid  those 
containing  considerable  quantities  of  nucleo-albumen  or  of  delete- 
rious products  of  tissue-change;  in  the  case  of  the  latter  (vegetable 
albumens),  she  should  avoid  those  likely  to  cause  undue  stimula- 
tion of  the  intestinal  tract.  Of  flesh  foods  (mammals,  birds,  and 
fishes),  those  kinds  are  to  be  preferred  which  contain  small  quanti- 
ties only  of  extractives  (kreatin,  xanthin,  etc.)  since  these  sub- 
stances are  supposed  to  have  a  stimulating  influence  upon  the 


SEXUAL  EPOCH  OF  THE  MENOPAUSE.  661 

nerves  and  the  heart.  Hence,  boiled  meat  is  better  than  roasted,  and 
the  flesh  of  young  animals  (veal,  for  instance)  and  fish  are  to  be 
preferred  to  game,  and  the  last-mentioned  is  to  be  avoided  especially 
for  this  reason,  that  the  flavours  for  which  it  is  valued  by  the 
gourmet  are  products  of  partial  decomposition  arising  from  pro- 
longed hanging;  for  similar  reasons,  meat  extracts,  animal  soups, 
sausages,  smoked  flesh  and  fish,  and  preserved  (potted)  meats, 
should  all  be  avoided.  From  the  intimate  connexion  between  the 
ingestion  of  nuclein  and  the  formation  of  uric  acid,  albumens  rich 
in  nuclein  are  to  be  forbidden ;  such  are  the  various  foods  consist- 
ing chiefly  of  gland-cells  —  sweatbread,  liver,  brain,  kidneys,  etc. 
As  well  as  from  the  appropriate  flesh-foods,  the  requisite  albumen 
may  most  suitably  be  obtained  from  eggs  and  milk  (including 
buttermilk)  ;  on  the  other  hand,  caviare  is  unsuitable  owing  to 
its  stimulant  action  on  the  genital  organs,  cheese  because  it  contains 
large  quantities  of  the  products  of  decomposition  of. casein  and 
milk- fat;  the  fermented  milks,  koumiss  and  kefir,  are  likewise  un- 
suitable. Suitable  vegetable  foods  for  the  supply  of  albumen  (in 
addition  to  carbohydrates)  are  porridge,  bread,  and  the  legumin- 
osae ;  nuts,  on  the  other  hand,  cause  too  much  irritation  of  the 
stomach  and  intestines. 

For  women  during  the  climacteric  period  we  recommend  a  mixed 
diet  moderate  in  quantity;  the  amount  of  flesh  and  fat  in  the  diet 
should  not  be  large,  whilst  cereals,  green  vegetables,  and  fruit  may 
be  taken  in  greater  abundance ;  irritant  vegetable  foods  must  be 
avoided,  and  especially  those  which  tend  to  stimulate  unduly  intes- 
tinal muscular  activity  and  intestinal  secretion.  It  is  important 
that  an  abundance  of  water  should  be  taken,  not  less  than  two  or 
three  pints  daily,  and  a  pure,  fresh,  spring  water  is  preferable  to 
the  aerated  waters,  natural  or  artificial.  Alcoholic  beverages  are 
to  be  avoided,  and  more  especially  those  which  are  rich  in  extrac- 
tives as  well  as  in  alcohol.  For  this  latter  reason,  beer  and  cham- 
pagne are  harmful,  whilst  spirits  and  liqueurs  are  to  be  condemned 
on  account  of  the  high  percentage  of  alcohol  they  contain.  The 
stimulating  alkaloidal  drinks,  tea  and  coffee,  are  also  to  be  avoided, 
or  if  taken  at  all,  only  in  a  very  dilute  form.  With  regard  to  the 
preparation  of  the  food,  the  cardinal  principle  is  that  it  should  be  as 
little  irritant  as  possible ;  neither  mechanically  irritating  the  aliment- 
ary tract  by  an  excess  of  indigestible  or  undigested  residue,  nor 
irritating  it  chemically  by  an  excessive  admixture  of  sugar,  salt, 
vinegar,  pepper  and  other  spices ;  nor,  finally,  giving  rise  to  thermal 
irritation  by  being  excessively  hot  or  extremely  cold. 

The  individual  meals  are  preferably  small  ones  and  they  must 
therefore  be  taken  at  comparatively  short  intervals,  five  times  daily, 
the  principal  meal  being  taken  at  one  or  two  o'clock  in  the  after- 


662  THE  SEXUAL  LIFE  OF  WOMAN. 

noon,  and  the  supper  (which  should  be  small)  comparatively  early, 
at  seven  or  eight  o'clock. 

NOTE. — In  his  discussion  of  the  details  of  diet  for  women  during  the 
climacteric  period,  hours  of  meals,  actual  dishes,  etc.,  the  author  reiers  ex- 
clusively to  Austrian  and  German  customs  in  these  matters.  The  translator 
has  not  attempted  to  adapt  the  following  pages  to  tne  needs  of  English 
readers,  as  he  feels  that  the  general  principles  already  given  will  enable  the 
English  medical  man  to  construct  without  serious  difficulty  suitable  diet- 
tables  for  the  cases  with  which  he  has  to  deal. 

Suitable  articles  of  food  are  the  following: 
Soups,  Broths,  and  other  Liquid  Foods :  Soups  and  broths  made 
from  the  flesh  or  bones  of  beef,  mutton,  veal,  chicken,  or  pigeon, 
without  the  addition  of  meat  extract,  or  of  meat  juices,  peptones, 
somatose  or  nutrose,  but  with  die  addition  of  barley,  oatmeal,  rice, 
wheatmeal,  ryemeal,  peas,  beans,  lentils,  vermicelli,  or  macaroni; 
also  broths  or  porridge  made  from  any  kind  of  ground  cereal,  or 
from  potatoes,  or  from  peas,  beans,  or  lentils. 

Flesh  Foods :  Lean  beef,  veal,  mutton,  roast  or  boiled,  pigeon, 
chicken ;  certain  fresh  fish  —  pike,  haddock,  sole,  perch,  and  trout. 
Unsuitable  are :  pork,  goose,  eels,  salmon,  herrings,  oysters,  cav- 
iare, lobster,  crab,  smoked  meat,  hare,  vension,  wild-duck,  brain, 
liver,  kidneys. 

Vegetables,  Sweets,  and  Savouries :  Green  peas,  spinach,  cauli- 
flower, carrots,  turnips,  buttered  eggs,  omelette,  boiled  and  baked 
puddings,  rice  boiled  in  milk,  apples  and  rice,  whipped  cream, 
salads,  wheaten  bread,  French  rolls,  biscuits,  and  rusks. 

Fruits:  Almost  all  fruits  may  be  taken,  raw,  cooked,  or  pre- 
served; also  in  the  form  of  currant  and  other  fruit  cakes,  and  as 
fruit-ices. 

Beverages:  Milk,  buttermilk,  water,  the  same  acidulated  with 
various  fruit-juices  and  essences  (as  lemonade,  etc.),  weak  tea  with 
plenty  of  milk,  cocoa,  chocolate.  To  be  forbidden  are :  beer,  strong 
and  sweet  wines,  distilled  spirits. 

An  example  is  subjoined  of  a  simple  diet-table  compiled  on  the 
above  principles : 

Quantity  Carbo- 

in  grams.      Albumen.  Fat.         hydrate. 

AFTERNOON  : 

A  cup  of  milk 150  5.4  5.4  7.3 

Roll  and  butter 70  4.9  0.4  39.2 

MIDDLE  OF  MORNING: 

Soup loo  i.i  1.5  5-7 

Roll 70  4.9  0.4  39.2 

MID-DAY  MEAL: 

Soup 100  i.i  1.5  5.7 

Roast  meat 100  38.2  1.7  

Green  vegetables    100  1.6  0.4  8.4 

Pudding 200  17.4  30.0  57.8 

Fruit loo  3.0  15.0 

Bread 3§  2.4  0.2  19.0 


SEXUAL  EPOCH  OF  THE  MENOPAUSE.  663 

Quantity  Carbo- 

in  grams.  Albumen.  Fat.  hydrate. 
BREAKFAST: 

A  cup  of  milk  . . . . 150  5.4  5.4  7.5 

Roll 70  4.9  0.4  39.2 

SUPPER  : 

Soup 100  i.i  1.5  5.7 

Two  soft  eggs 90  ii. 2  10.8  0.4 

Bread 70  4.9  0.4  39.2 

Fruit,  .' loo  3.0            15.0 

Total 1,617  110.5  69.9  304.5 


In  addition,  water,  ad  libitum,  and  perhaps  a  little  light  wine. 

In  many  cases,  however,  a  mainly  vegetarian  diet  may  be  more 
suitable,  and  more  particularly  a  mainly  fruit  diet,  in .  order  to 
diminish  persistent  congestive  symptoms.  In  such  cases  the  fol- 
lowing diet-table  may  be  recommended  for  short  periods: 

First  breakfast:     An  apple  and  an  orange. 

Second  breakfast:  25  grams  of  white  bread  with  butter  and 
three  baked  apples. 

Dinner  (mid-day)  :  100  grams  fish  or  meat,  potatoes,  green 
vegetables,  3  boiled  or  baked  apples. 

Afternoon:     An  orange,  or  an  apple,  or  a  pear,  or  some  grapes. 

Supper:     Milk,  apples  and  rice,  oranges,  grapes,  figs. 

Beverages:     Water,  with  or  without  fruit  juices  or  essences. 

Changes  in  the  above  diet-table  could  very  readily  be  effected, 
whereby  the  quantity  of  carbohydrate  could  be  increased  and  the 
quantity  of  albumen  lessened. 

In  women  of  sanguine  temperament  and  full  habit  of  body,  who 
at  the  time  of  the  menopause  very  rapidly  become  obese,  important 
changes  in  the  diet  become  necessary.  The  main  principles  of  a 
fat-reducing  diet  are  the  following:  Avoidance  of  all  over- feeding, 
reduction  of  the  quantity  of  food  taken  below  the  former  average 
amount,  with  retention,  however,  of  a  sufficiency  of  nutrient  ma- 
terial to  maintain  the  metabolic  equilibrium  of  the  essential  tissues ; 
the  maintenance  of  this  metabolic  equilibrium  demands  a  sufficiency 
of  nitrogenous  foods,  but  the  fats  in  the  diet  may  be  reduced  to  a 
minimum,  and  the  carbohydrates  may  also  be  very  greatly  dimin- 
ished. At  the  same  time,  there  must  be  systematic  bodily  exercise, 
and  the  hours  of  sleep  must  not  exceed  a  nightly  average  of  seven. 

For  obese  women  at  the  climacteric  period,  a  suitable  aver- 
age diet  would  contain  160  grams  albumen,  12  grams  fat,  and 
1 20  grams  carbohydrate,  yielding  a  daily  heat-equivalent  of  1,250  to 
1,300  calories. 


664                      THE  SEXUAL  LIFE  OF  WOMAN. 

A  sample  diet-table  constructed  on  these  principles  is  appended: 

Quantity  Carbo- 

in  grams.  Albumen.  Fat.         hydrate. 
BREAKFAST: 

A  cup  of  weak  tea 150  0.45            0.9 

with    milk,    but    no 

sugar 30  1.29  0.9                  1.2 

White  bread    SO  4.8  0.4               30.0 

Lean  cold   meat 50  19.1                   0.9            

DINNER   (Mid- Day)  : 

Small- cup  of  clear  soup.              loo  1. 1  1.5                  5.7 

Lean  beef   200  76.4                   3.4            

Green    vegetables,    salad, 

etc loo  1.6  0.4                8.4 

Fruit loo  3.0              15.0 

Roll 35  2.4  0.2               19.6 

AFTERNOON  : 

A  cup  of  weak  tea 150  0.45            0.9 

With    milk,    but    no 

sqgar 30  1.29  0.9                  1.2 

SUPPER  : 

Soup loo  i.i  1.5                5.7 

Lean  roast  meat 100  38.2                   1.7            

Roll 50  4.8  0.4               30.0 


Total  1,245  155.9  13.2  118.6 


In  the  selection  of  individual  articles  of  diet,  it  is  important  to 
bear  in  mind  the  fact  that  in  all  climacteric  women  it  must  be  our 
aim  to  stimulate  intestinal  muscular  activity  (peristalsis)  and  in- 
testinal secretion  to  a  moderate  extent,  for  by  more  active  intes- 
tinal secretion  abdominal  congestion  is  to  some  extent  relieved,  and 
by  intestinal  transudation  and  by  diminution  of  the  lateral  pressure 
the  circulation  through  the  abdominal  vessels  is  facilitated.  By 
thus  lowering  the  intra-abdominal  blood-pressure,  we  shall  assist 
in  relieving  a  number  of  chronic  hyperaemic  states  of  the  pelvic 
and  various  other  organs,  from  which  women  are  prone  to  suffer 
at  the  menopause.  Hence  all  articles  of  diet  must  be  forbidden 
which  have  a  tendency  to  give  rise  to  constipation.  But  we  must 
also  forbid  all  substances  which  leave  extensive  undigested  residues, 
such  as  the  rinds  of  fruits,  large  quantities  of  porridge,  etc.,  hard 
meats,  nuts,  and  the  like.  Most  suitable  are  those  articles  of  diet 
which  contain  large  percentages  of  fluid  constituents,  such  as  milk, 
thin  soups,  weak  tea  (infused  only  a  short  time,  so  as  to  contain 
little  tannic  acid,  which  is  very  constipating),  white  meat  —  veal, 
breast  of  chicken,  etc.  Of  vegetables,  those  are  best  which  contain 
plenty  of  water  and  an  abundance  of  the  organic  acids,  young, 
fresh  garden  produce,  lettuce,  cauliflower,  young  green  peas,  young 
carrots,  turnips,  etc.  Juicy  fruits  are  good,  apples,  pears,  cherries, 
and  plums.  Butter  and  honey  are  also  excellent.  In  many  per- 


SEXUAL  EPOCH  OF  THE  MENOPAUSE.  665 

sons  suffering  from  constipation,  all  that  is  necessary  for  their  re- 
lief is  to  give  a  tumblerful  of  cold  water  the  first  thing  in  the  morn- 
ing; with  others,  the  use  in  addition  of  whole-meal  bread  with 
plenty  of  butter  and  honey  and  uncooked  fruit,  is  required. 

In  women  suffering  from  the  various  disturbances  of  the  climac- 
teric period  in  an  aggravated  form,  either  because  the  menopause 
occurs  at  an  unusually  early  age,  or  because  the  suppression  of 
menstruation  has  taken  place  suddenly  instead  of  gradually  —  es- 
pecially in  cases  of  heart-trouble,  severe  vertigo,  pronounced  vaso- 
rnotor  disturbances,  or  mental  excitement  (also  erotic  excitement), 
I  have  sometimes  found  a  methodical  milk-cure  carried  on  for 
several  weeks  most  beneficial.  By  this  I  do  not  mean  an  exclusive 
diet  of  milk,  but  a  diet  consisting  chiefly  of  milk  and  milk-foods ; 
owing  to  the  absence  of  all  irritation  of  the  nervous  and  vascular 
systems,  this  diet  has  a  very  definite  sedative  influence  in  such  cases. 
The  milk  should  be  skimmed,  and  should  be  given  four  times  daily 
in  gradually  increasing  quantities,  the  total  amount  rising  from  ten 
ounces  to  fifty  ounces  daily.  The  only  other  meal  should  be  a  sub- 
stantial mid-day  dinner,  consisting  of  soup,  roasted  white  meat, 
young  green  vegetables,  and  a  little  fruit.  In  some  instances,  to 
prevent  constipation,  it  is  necessary  to  add  ten  grams  of  milk  sugar 
to  each  glass  of  milk ;  in  other  cases  it  is  necessary  to  dilute  the 
milk  with  water.  It  is  obvious  that  the  quantity  of  milk  given  is 
not  alone  sufficient  to  maintain  the  metabolic  equilibrium  of  the 
body;  but  the  defect  in  this  respect  is  made  up  by  the  substantial 
meal  given  at  mid-day. 

Among  the  stimulating  influences  which  during  the  sexual  epoch 
of  the  menopause  are  as  far  as  possible  to  be  avoided  we  must  un- 
hesitatingly include  the  practice  of  coitus,  inasmuch  as  at  this  time 
of  life  there  already  exists  a  strong  tendency  towards  the  occur- 
rence of  hyperaemia  of  the  reproductive  organs ;  and  sexual  inter- 
course, increasing  as  it  inevitably  must  this  tendency  to  hyperaemia, 
should  be  indulged  in  as  little  as  possible.  And  yet  precisely  in 
women  of  the  climacteric  age,  in  "  la  femme  demi-vieille  "  there  often 
exists  a  strong  desire  to  drain  the  cup  of  sexual  pleasure  to  its 
dregs.  Not  infrequently,  therefore,  the  physician  is  asked  to  ad- 
vise regarding  the  proposed  marriage  of  a  woman  in  whom  the 
menopause  is  drawing  near,  the  desired  husband  being  young,  or  at 
least  still  fully  virile.  If  the  advice  is  given  in  all  sincerity  with  a 
sole  eye  to  the  woman's  health,  the  medical  man  will  definitely  for- 
bid the  marriage. 

When,  however,  the  changes  of  the  menopause  are  fully  com- 
pleted, when  the  woman's  reproductive  organs  have  undergone 
complete  senile  atrophy,  there  is  no  medical  reason  why  a  couple 
who  wish  to  give  a  tenderer  name  to  an  intimate  friendship  be- 


666  THE  SEXUAL  LIFE  OF  WOMAN. 

tween  man  and  woman,  should  refrain  from  marriage  —  provided 
that  both  have  attained  a  like  stage  of  sexual  decline.  "  But," 
writes  Tilt,  "  a  union  between  frosty  January  and  blooming  May 
is  likely  to  be  as  dangerous  to  the  health  as  it  is  to  the  happiness 
of  both." 

Whilst  attending  to  the  regulation  of  the  physical  diet  of  his  cli- 
macteric patient,  the  physician  should  not  overlook  her  psychical 
regimen.  A  woman's  mind  is  very  powerfully  affected  by  the  proc- 
esses of  the  menopause.  On  the  one  hand,  her  fears  are  stimulated 
by  the  thought  that  she  is  entering  upon  the  "  critical  age,"  of  whose 
dangers  she  has  often  been  warned ;  and,  on  the  other  hand,  she  is 
mentally  depressed  by  the  knowledge  that  she  is  about  to  lose  the 
charms  of  womanhood,  and  to  decline  in  sexual  esteem.  It  is  well, 
therefore,  for  women  during  the  years  of  change,  to  have  some 
kind  of  employment,  which  fills  their  hours,  occupies  their  thoughts, 
and  —  leaves  a  certain  scope  for  the  exercise  of  feminine  vanity. 
Works  of  benevolence  or  of  general  utility,  and  literary  occupa- 
tions, are  thus  of  great  advantage  to  climacteric  women.  Plato, 
indeed,  pointed  out  that  women  at  this  time  of  their  lives  should 
occupy  themselves  with  literature  and  intellectual  culture. 

Just  as  it  is  the  duty  of  the  physician,  more  especially  of  the 
family  physician,  to  enlighten  the  maiden  on  the  threshold  of  her 
sexual  development  regarding  the  processes  of  the  awakening  sex- 
ual life,  and  to  give  her  the  necessary  instruction  concerning  the 
hygienic  measures  which  it  is  proper  for  her  to  adopt  —  so  also  is 
it  his  duty  to  convey  medical  information  to  the  woman  who  stands 
on  the  threshold  of  sexual  decadence.  A  woman's  ignorance  is 
often  equally  profound  at  both  these  epochs  of  the  sexual  life.  A 
woman  in  the  early  forties  often  does  not  suspect,  or  at  least  re- 
fuses to  acknowledge,  that  she  is  gradually  drawing  near  to  the  end 
of  her  sexual  life ;  and  she  is  still  farther  from  the  knowledge  that 
definite  rules  of  general  and  sexual  hygiene  must  be  observed  by 
her  if  she  wishes  to  minimize  the  dangers  of  the  critical  period. 

The  medical  friend,  in  an  earnest  though  far  from  gloomy  man- 
ner, will  expound  to  her  the  nature  of  the  physiological  processes 
of  the  menopause,  and  will  instruct  her  regarding  the  correspond- 
ing preventive  measures  —  diet,  exercise,  clothing,  care  of  the  skin, 
and  the  regulation  of  sexual  intercourse.  Moreover,  the  physician, 
by  means  of  skilfully  directed  enquiries  regarding  certain  symp- 
toms, will  be  enabled  to  gain  early  information  about  the  occurrence 
of  abnormal  processes  at  this  period  of  life,  and  will  in  this  way 
detect  the  first  beginnings  of  many  diseases  which  are  amenable 
to  treatment  only  at  the  very  outset  of  their  course.  For  example, 
Brierre  de  Boismont,  an  early  and  accurate  observer  of  this  sexual 
epoch  in  the  life  of  woman,  points  out  that  in  cases  in  which,  during 


SEXUAL  EPOCH  OF  THE  MENOPAUSE.  667 

the  change  of  life,  a  woman  experiences  an  increased  inclination 
for  sexual  intercourse,  nineteen  times  out  of  twenty,  a  local  exami- 
nation will  disclose  the  existence  of  some  disease  of  the  repro- 
ductive apparatus.  Similarly,  every  gynecologist  is  now  familiar 
with  the  fact  that  unusually  free,  atypical  haemorrhages  during 
the  climacteric  period,  are  commonly  indications  of  the  existence  of 
a  uterine  neoplasm. 

Much  evil  may  be  avoided,  and  much  suffering  can  be  diminished 
if  the  physician,  in  accordance  with  the  advice  of  Hippocrates,  does 
not  limit  his  activities  strictly  to  the  exercise  of  the  healing  art, 
but  stands  by  a  woman's  side  as  her  mentor  and  confidant  during 
the  troublesome  years  of  her  sexual  decline.  And  he  will  best  fulfil 
these  functions,  if  he  succeeds  in  convincing  the  climacteric  woman 
of  the  profound  truth  embodied  in  the  saying  of  the  great  French 
philosopher : 

Qui  n'a  pas  1'esprit  de  son  age, 
De  son  age  a  tout  le  malheur. 


INDEX. 


[References  are  to  pages.] 


Abdominal  pains,  46. 

Abdominal  pressure,  46. 

Aberration,  moral,  46. 

Absence  of  mind,  154. 

Absence    of   ovaries,    182. 

Abnormalities,   mental,    155. 

Abortion,  223,  414. 

Abstinence,  256,  398. 

Acromegaly,   102. 

Act  of  intercourse,  84. 

Activity,  sexual  in  women,  597. 

Acton,  276. 

Actual  intercourse,  84. 

Adamites,  302. 

Africa,  43,  45. 

Age,  average,  at  marriage,  200. 

Agineta,  464. 

A  hi f  eld,  308/333,  424,  448. 

Air  hunger,  419. 

Albert,  331. 

After tus  Magnus,  I. 

Albini,  454. 

Albuminaria,  93. 

Alcohol,  155,  258,  270. 

Algeri,  155. 

A  liber  t,  408,  Sp7. 

Almquist,  262. 

Alt  f  eld,   482. 

Amenorrhcea,   84,    128,    160. 

Amentia,   103. 

America,  43. 

Amputation  of  clitoris,  184. 

Amitssat,  542. 

Amyntor,  219. 

Anaesthesia,   184,  187. 

Anatomical  changes,  8,  50,   141, 

Anderson,  331. 

Andral,  582. 

Aneurism,  98. 

Anger,  183. 


Angina  pectoris,  240. 

Anjel,  191. 

Anomalies  of  vagina,  331. 

Antipathic   sexuality,    194. 

Antitoxic  functions,  21. 

Ansell,  365,  466,  561. 

Ansty,  135. 

Anxiety  neurosis,  405. 

Apes,  22. 

Appetite,  loss  of,  46,   107. 

Aqueo-mucous  vaginal  discharge,  46. 

Arabian  women,  30. 

Aran,  632. 

Areola  mammae,  208. 

Aretaeus,  i. 

Aristotle,  i,  211,  392,  420,  463,  473, 

498,  544. 
AriuSj  502. 
Arndt,  233,  343,  418. 
Arthritis,  635. 
Artificial   fertilization,  317. 
Asher,  406,  538,  541,  559,  563. 
Ashwell,   109. 
Asia,  42. 

Aspermatism,  317. 
Athenaeus,  302. 
Atlee,  474,  603. 
Atmocausis,  419. 
Atri,  266. 

Atrophy,  concentric,  590. 
Atrophy,  excentric,   590. 
Atrophy,  gradual,  592. 
Atrophy  of  uterine  muscle,  609. 
Azoospermia,  316. 

Babbage,  433. 
Bacon,  271. 
Bacterial  flow,  593. 
Baer,  616. 
Bain,  203. 
[669] 


670 


INDEX. 


[References 
Bailey,  183. 
Baillarger,  438. 
Bainbridge,  331. 
Baker-Brown,  546. 
Balcstra,  575. 
Ball,  156. 
Balzac,  193. 
fianrf/,  536,-  557. 
Barker,  556. 
Barnes,  161. 
Barthels,  47,  331. 
Bartholin's  glan'd,  529. 
Basjch,  296. 

Baths,   116,    117,  280,  654. 
Battey,  475,  564. 
Baumes,  260. 
Bautngarten,  166. 
Baust,  441. 
Bazaraignes,  434. 
Beard,  106,  405. 
Beauty,  attribute  of,  23. 
Beauty,  curve  of,  24. 
Beauty,  decline  in,  23. 
Beauty  of  woman,  200,  206. 
B<?^/,  77,  394,  401,  415. 
Beck,  296. 
Becker,  305. 
Bednar,  478. 
r,  161. 
/,   165,  300,  496,   505,   517,  525, 

604. 

Belot,   193. 
Bcnnet,  64,  88,  632. 
Bensler,  540. 
Bergh,  210,  496. 
Bernard,  78. 
Bernstein,  365. 
Bertttlon,  218,  264,  382. 
Berwits,   101. 
Bidder,  436,  439. 
Biermier,  412. 
Billroth,  337. 
Birc/t,  305. 
Birkett,  619. 
Birsmont,  29,  42,  45,   135,   594,  603, 

607,  666. 
Bishoff,  136,  140. 
Bladder,  irritable.  107. 


are  to  pages.] 

Blindness,  108. 
Blondes,  45. 
Blood,  anomalies  of,  478. 
Blood  pressure,  16. 
Blumenbach,  132. 
Blundell,  90,  417,  568,  603. 
Blushing,  spontaneous,  46. 
-See*,  353- 

Bodily  exercise,  658. 
Boehm,  62,  331. 
Bomer,  182,  618,  629,  632,  640. 
So/w,  635. 
Boileux,  419. 
Boinet,  474. 
Boireau,  2. 
Boivin,  498. 
Bonton,  88. 
Bonvalot,  17. 
Books,   121. 
Bordier,  556. 
Borw,  305,  456. 
Bot.termund,  146. 
Bossi,  607. 
Bouchardat,   130. 
Bowditch,  46.  • 

Bowels,  regulation  of,  121. 
Boyd,  496. 
Bradlaugh,  393. 
Braid,  494. 

Braun,  234,  326,  332,  438,  446. 
Breasts,  213. 
Brehm,  416. 
SrmA-y,  326,  334,  515. 
Breslau,  423,  435,  437.  ' 
Breuer,  92. 
Bri//,  326. 
Brouardel,   72. 
Brown-Sequard,  20,  587. 
Bruce,  364. 
Brunettes,  45. 
Brunt  sel,  182. 
Buckle,  378. 
Buddha,  168. 
Buffon,  167. 
Bulimia,   107. 
Buhver,  260. 
Burdach,  294,  466. 
,  413. 


INDEX. 


671 


Burggraeve,  496. 
Burkart,  473. 
Burton,  515. 
Busch,  2,  580. 
Bittlin-Smythe,  235. 
193. 


Csesarean   section,  567. 

C  alder  mi,  44. 

Campbell,   443. 

Cantharides,   186. 

Capellmann,  400. 

Capwron,  482. 

Cardiac    disorders,   94,  97,    236,    243, 

344,  626. 

Cardiopathie  de  la  menopause,  629. 
Cardiopathy,  uterine,  235. 
Care  of  genital  organs,  279. 
Care  of  skin,  658. 
Carey,  394. 
Carlisle,  393. 
Cariicr,   195. 
Car  us,  80,  364. 
Casper,   189,  292,  547. 
Castan,  86. 
Castration,   419,   475. 
.Catamenial   flow,  83. 
Catarrh,  gastric,  229. 
Cattarrh  in  vagina,  614. 
Catarrh  in  vulva,  614. 
Cattlebreeders,    358. 
Causes     of     early     development     of 

menarche,  49. 
Causes    for   lack   of    sexual   impulse, 

188. 
Causes    for   intensity   of    sexual   im- 

pulse,  188. 

Causes  of  ungrati  tying  coitus,  357. 
Caustics,  119,  568. 
Cavum  uteri,  56. 
Celibacy,   173. 
Celsus,  463. 

Cervix  uteri,  absence  of,  506. 
Cervix  uteri,  deformities    of,   503. 
Cervix  uteri,  hypertrophy    of,    334. 
Cervix  uteri,  ideal    form   of,   502. 
Cervix  uteri,  normal    form   of,    502. 


[References  are  to  pages.] 

Cervix  uteri,  pathological  changes  of, 

501. 

Champignon,  556. 
Champonicrc,    17. 
Change  of  life,  571. 
Changes   in   the   skin,    148,  208. 
Characteristics,  inherited,  25. 
Char  cot,  100. 
Charr  in,  21. 
Chassaignac,  107. 
Chassagnc,  260. 
Chastity,   123. 
Chazan,   138. 
Checks     to    increase    of    population, 

391- 

Chevin,  466. 
Chiari,  438,  490,  616. 
Chlorosis,  21,  86,  91. 
Christianity,  diffusion  of,  6. 
Chrobak,  214,  298. 
Chronic  endometritis,  87. 
Chronic  metrometritis,  87. 
Circulatory  organs,   149,  240,  620. 
Circumcision  of  women,  328. 
Civilization,  progress  of,  6. 
Clarke,  443. 

Cleanliness  of  genital  organs,  658. 
Cleft,  vulvar,  51. 
Clement,  629. 
Cleveland,  482. 
Climacteric  insanity,  643. 
Climacteric  phenomena,  600. 
Climacteric  psychoses,  643. 
Climacteric  psychoses,   prognosis   of, 

653- 

Climacterium,   571. 
Climacterium,  dangers  of,  578. 
Climatic  conditions,  27,  37,  117,  132. 
Clitoris,  74,  330. 
Clitoris  crises,  352. 
Clothing,    114,   121. 
Coccygodynia,   107. 
Coffee,  121. 
Coffignon,  189. 
Cohen,  108. 
Cohn,  .148. 

Cohnstein,  402,  548,  558,  634. 
Coitus   interruptus,   345. 


672 


INDEX. 


[References 
Coitus,  obstacles    to    completion    of, 

335- 

Coitus,  prohibitive,  529. 
Coitus,  undue  frequency  of,  294. 
Cold  nature,  188. 
Cold  sponging,  28i. 
Cole,  553. 
Collins,   139. 
Colpotomy,  418. 
Coinbys,  79. 
Comedones,  no. 

Compensation,    disturbances    of,   254. 
Competence  for  marriage,  250. 
Conception,    137,   299,   304,    308,    366, 

483- 

Conditions  essential  to  procreation, 
469. 

Condoms,  405,  409. 

Confucius,  385. 

Congestion,   premenstrual,    142. 

Congfou,  403,  547. 

Congressus  interruptus,  220,  225. 

Congressus   reservatus,  225,  227. 

Conjugation,    interference   with,  487. 

Conjunction,   108. 

Conservants,    109. 

Constipation,  107,  228. 

Constitution,  38. 

Constitutional  conditions  and  meno- 
pause, 599. 

Constrictor  cunni  muscle,  348. 

Consumption    of    nitrogen,    22. 

Continence,  sexual,  400. 

Continence,    sexual,    enforced,    172. 

Contraction,  pelvic,  334. 

Contrectation,   176. 

Control  of  instinctive  impulses,  25. 

Control     of     reproductive     function, 

397- 

Convulsions,   152. 
Cook,  302,  443. 
Cooper,  659. 

Copulation,  200,  284,  323. 
Corpora  albicantia,  592. 
Corpora  fibrosa,  592. 
Corpus  luteum,  59. 
Corset  liver,  122. 
Corsets,  90,  122. 


are  to  pages.]. 

Cosmophil  nerves,  17. 

Coste,  136,  304,  454. 

Courty,  25,  29,  46,  132,  329,  361,  5.49, 
594,  603,  €07. 

Craisson,  292. 

Crampe,  380. 

Credc,  494. 

Crimes  committed  during  menstru- 
ation, 159. 

Critical  age,  571. 

Critical  period,  572. 

Croom,    164. 

Cros,  378. 

Cruise,  494. 

Culture,  modern,  6. 

Curetting,    119. 

Currier,  609. 

Curve  of  the  sexual  life  of  woman, 
4- 

Cyan,  16. 

Cysts,   588. 

Dangers  to  sexual  life,  276. 
Dante,  171. 

Dark  rings  around  the  eyes,  46. 
Danvin,  170,  376,  379,  380,  449,  485, 

545- 

Davis,  340,  484. 
Dccaisne,   165. 
Defloration,   326. 
Degeneration,  stigmata  of,  387. 
DC  Graaf,  136. 
Dehay,  168,  482. 
Dehio,  116. 
DC  la  Motte,  364. 
Delivery,  previous,  560. 
Dclusianne,  258. 
Demange,  21. 
Demosthenes,  271. 
Denis,  130. 
Denman,  555. 

Dental  transverse  ridges,  57. 
Derangement,    103. 
D'E spine,  40,  82,  477,  538. 
Desque,  128. 

Determinants  as  to  marriage,  259. 
Determination  of  sex,  420. 


INDEX. 


673 


Determination  of  sex,  influences  on, 

421,  436,  445. 
Detumescence,   176. 
De  Villeneuve,  144. 
Dcvillieres,  337. 
Dcivees,  365. 
Diamant,  79,  158. 
Diarrhoea,    144. 
Diderot,   192. 
Diet,   112,   127,  659. 
Diet,  regulation  of,  660. 
Digestion,    disorders    of,    107. 
Digestive  organs,  145,  630. 
Diminution    of    procreative    capacity, 

401. 

Diodes,   381. 
Disinclination    to    physical    exercise, 

93- 

Disorders,  various,  85, 
Disparity  in  age,  265. 
Disturbances,    nervous,   587. 
Disturbances  of  general  system,  587. 
Dohm,  527. 
Doran,  617. 
Double  chin,  572. 
Doubleday,  485. 
D'Outreport,  80. 
Dragging  sensations,  46. 
Dreams,  erotic,   107. 
Dubois,  135. 
Duchatelet,  477. 
Duercr,  210. 

Duesing,  231,  424,  442,  449,  453. 
Dugcs,  498. 
Duhousset,  190. 
Duke,  480. 
Duncan,   146,  360,  367,  377,  466,  484, 

513,  546,  562. 
Dunlap,  165. 
Dunn,  161. 
Duplay,  494. 
D litres,  614. 
Dupruyten,  494. 
Duration    of    sexual    period,    26,    30, 

130,  181. 

Dysmenorrhoea,    160. 
Dysmenorrhoea,   inflammatory,    162. 
Dysmenorrhcea,   intermediate,   164. 

22 


[References  are  to  pages.] 

Dysmenorrhcea,  mechanical,   162. 
Dysmenorrhcea,  nervous,  162. 
Dysmenorrhcea,  symptoms,  of,  163. 
Dyspareunia,   187,  347,  355,  358,  359. 
Dyspepsia,  23,    107,  227,  229,  631. 


Edcbohls,  165. 

Edis,  294. 

Effects  of  marriage  on  hysteria,  25? 

Efferts,  173. 

Egger,  118. 

Eggle,  211. 

Eichstadt,  298. 

Eisenhart,  107,  2*34. 

Ejaculatio  praecox,  225. 

Ejaculation,  349. 

Elberskirchen,  173. 

Elder,  235. 

Elephantiasis  of  labia,  530. 

Elliott,  395. 

Ellis,   169. 

Elsaesser,  438. 

Emancipation,  200. 

Embrace,  intimate,  84. 

Emmet,  45,  150,  414,  473,  522,  604. 

Endogamy,  386. 

Endometritis,  87,  235,  611. 

Energy  of  woman,  200. 

Engagement,   142. 

Engel,  494. 

Engclhardt,  244. 

Engeltnann,  137,  142. 

English,  293. 

Engstroem,  40. 

Enlightenment    of    young    girls,    35. 

124,  273. 

Enteroptosis,   90. 
Epilepsy,   102,  257. 
Epithelioid   cells.  60. 
Epistaxis,    165. 
Equal  moral  rights,  264. 
Equilibrium,  mental,   153. 
Erb,  172. 

Erethism,  sexual,  575. 
Erlmcyer,  473. 
Eroess,   78. 
Erotic  dreams,  107. 
Erotic  element,  173. 


674 


INDEX. 


[References 
Erotic  problem,  264 
Erotic  sphere,  172. 
Eroticism,  652. 
Erysipelas,  634. 
Esquirol,  81,  646. 
Etienne,  21. 
Etogamy,  386. 
Ewlenburg,    123,    199,    338,    354,   402, 

405v 

Europe,  middle,  41. 
Europe,  southern,  42. 
Eustache,  293. 
Excess,  habitual,  406. 
Excess,  sexual,  560.. 
Excessive    prudery,    88. 
Excessive  sexual  desire,   178. 
Ezekiel,  47. 

Facial  aspect,  46. 

Fainting  fit,  102. 

Fallopian  tube,  489,  568. 

False  shame,  340. 

Family  life,  5. 

Febris   amatoria,  92. 

Federns,   16. 

Feeling  of  weakness,  46. 

Feeling  of  numbness,  46. 

Fehling,  17,  396,  407. 

Fellner,  260. 

Female  companion,  192. 

Female  organs,  diseases  of,  83. 

Feokstitow,  309. 

Ferdy,  409. 

Fere,  258. 

Ferrero,  302. 

Fertility  in  woman,  363. 

Fertility,  conjugal,  382. 

Fertility,  ideal  of,  365. 

Fertility,   influences   on,  374,  378. 

Fertility,  maximum,  373. 

Fertility,  monogenous,  373. 

Fertility  of   female  criminals,  382. 

Fertility  of  prostitutes,  382. 

Fertility,  physiological,  365. 

Fertility,  restriction  of,  388. 

Fertilization,   137,  300,  305,  317,  321, 

322. 
Feydeau,  193. 


are  to  pages.] 

Finkelstein,  148. 

Finlayson,  366. 

Piquet,  450,  454. 

Fischel,  165. 

Flamerdinghe,   525. 

Flaubert,  193. 

Fleischer,   16. 

Flcischmann,   146,   165. 

Flow,  suppression   of,    103. 

Follicles,  graafian,  57. 

Follicles,  primitive,  57. 

Follicles,  ripening,  61. 

Foods  suitable  for  menopause,  662. 

Foerster,  489. 

Fordyce,  556. 

Forensic  significance  of  women  dur- 
ing menses,  159. 

Foster,  135. 

Fraenkel,  86,  91. 

Franchi,   165. 

Frank,  331,  466. 

Free  love,  261. 

Free  secretions,  51. 

Freedom  of  the  male,  33. 

Freedom,    sexual,  264. 

FrerichSf   632. 

Freud,  405. 

Freund,  103,  223,  225,  490,  494,  527, 
601. 

Fricke,   109,   438,  448. 

Pricker,  165. 

Friedmann,  100,  104,   157. 

Friedreich,   108. 

"  Friends,"   193. 

Frigidity,  partial,  1731 

Fritsch,  143,  320,  341,  506,  519,  537, 
555,  566,  600,  614,  619. 

Froehlich,  86. 

Frommel,  602. 

Froriep,  417,  568. 

Frost,  343. 

Fuchs,  646. 

Fiirbringer,  168,  312,  317,  406,  535. 

Fiirst,  440,  491. 

Function,    sexual,    173. 

Galen,  i,  77,   135,   187,  210,  251,  420. 
Gallard,  88. 


INDEX. 


675 


[References 

Gallemairts,  165. 

Carat,  652. 

Gastric  secretion,  228. 

Gastro-intestinal   affections,   235. 

Can  tier,  193,  318. 

Gavaret,  582. 

Gebhard,  40,  79,  138,  142,  163. 

Geissler,  427. 

Geist,  637. 

Gendr'm,  136. 

General  disturbances,   145. 

General  fatigue,  46. 

General  weakness,  46. 

Genital   organs,   diseases  of,   529. 

Genital   organs,  secretions   of,  528. 

Genital  organs,  secretions  of,  re- 
actions of,  529. 

Gcrbc,  453. 

Gilbert,  89. 

Gilles  de  la  Tourette,   109. 

Gillirray,  415. 

Giordano,    172. 

Giraud,  156,  186,  318. 

Girdles  of  chastity,  417. 

Girdzvood,  136. 

Glaevecke,  138,  166,  182,  575,  629, 
644. 

Glands,  reproductive,  20. 

Glands,  sebaceous,  51. 

Globules,  polar,  305. 

6 'Hinder,  537. 

Godefroy,  482. 

Goehlcrt,  370,  380,  423,  427,  443,  466. 

Goethe,  3,  120,  167. 

Goitre,  108. 

Colts,  21,  237. 

Gonococcus,  26. 

Gonorrhea,  200,  220,  278,  511. 

Gonorrheal   infection,  533,  555. 

Goodell,  183,  406,  515,  575. 

Goodman,   18. 

Gosselin,  534. 

Gottschalk,  235,  603,  612. 

Graafian   follicles,  57,  584,  587. 

Gracfc,  398.  406. 

Graily-Hci^it,    254,   296. 

Grawits,  go. 

Great  uterine  plexus,  16. 


are  to  pages.] 
Grechen,  539. 

Greeks,  unchastity  of,  192. 
Grenser,  521. 
Griesheim,  456. 
Griessinger,   103,  653. 
Grillparzer,   285. 
Grimaldi,  81. 
Gtisolle,  260. 
Grohe,  298,  473. 
Grilnewald,  467,  532,  551,  559. 
Griinfeld,  no,  118,  209,  409. 
Grusdeff,  41. 
Gunzberg,  410. 
Gurriere,  87,  382. 
Gusserow,  494,  525,  616. 
Gutceit,   105,  289,  350,   545. 
CM?,  30,  596,  603. 
Gynandry,  190. 

Gynecological    examination,    119. 
Gyurkovecky,  315. 

Haeckel,   460. 

Haemicrania,  100,  154. 

Hsemmorhages,  604. 

Hsemotopoiesis,    21,    89. 

Halm,  165. 

Hair,  pubic,  51,  no. 

Hater,  80. 

"Half  old,"  576. 

Holler,  2,  364,  544. 

Hammerschlag,  89. 

Hammond,   258. 

Ham pe,  426. 

Hanau,   260,  478. 

f/a»£,   148. 

Hannover,  31. 

Hardening  of  constitution,  25. 

Harley,  320. 

Hartmann,  202,  416. 

Haschcck,  482. 

Hosier,  306. 

Ha«/F,  182. 

Hausmann,  299,  331,  408. 

Haycraft,  378. 

Hay  em,  113. 

Headache,   107. 

Heart,  degeneration  of,  238. 

Heart,  female,  at  puberty,  98. 


6;6 


INDEX. 


[References 

Heart,  puberal  development,  98. 

Heart,  spasms  of,  98. 

Heat,  136,  139. 

Heat,  fugitive,  577,  581. 

Hebe,  210. 

Hebephreny,   101. 

Heber,  148. 

Hebra,  146,  634. 

Hecker,  308,  424,  438. 
Hcdin,  466. 

Hegar,  17,  91,  140,  168,  173,  182,  218, 
224,   243,  278,  282,  292,  346,   386, 
597,  564- 
Heidenreich,  108. 

Heinberger,   108. 

Heine,  98. 

Heitsmann,  147,  325. 

Hellwald,   181. 

Helmont,  2. 

Hemsbach,  438. 

Henle,  58,  597. 

Hennig,  19,  99,  215,  333,  493,  556. 

Henoch,  632. 

Hcnrick,  235. 

Hensen,  137,  179,  249,  304,  308,  348, 

422,  439,  449. 
Hensinger,  165. 
Heppner,  495. 

Hereditary  predisposition,  245. 
Herman,  343,  612. 
Hermes,  565. 
Herodotus,  185,  301. 
Herpes,   in. 
Hettstenius,  383. 
Hewitt,  522. 
/f^,  46. 

Hildebrandt,  341,  511. 
Hipocrates,  i,  101,  103,  129,  135,  306, 

381,  420,  480,  502,  631. 
Hirsch,   135. 
Hirschfeld,  305. 
Hirf,  405. 
HJJ,  304. 
Hoesslin,  405. 

Hofacker,  422,  426,  429,  434. 
Hoffmann,  69,  74,  89,  296,  331,  334, 

344,  496. 
Hofmeier,  80,  305,  484,  525,  536. 


are  to  pages.] 
Hohl,  296. 
Hollaender,   100. 
Hoto,  300,  475,  523. 
Homosexuality,  189,  198,  548. 
Horace,  271. 
Horn,  432. 
Horse  breeders,  358. 
Hortle,  165. 
Horton,  326. 

Hottentot  apron,  272,  328. 
Hue  hard,  252.  v 

Hughes,   100. 
Humbold,  2. 

Humming  top  murmur,  96. 
Hunter,  486. 
Hydrometra,  613. 
Hydrotherapeutics,   115. 
Hygiene  during  menacme,  261. 
Hygiene  during  menarche,   in. 
Hygiene  during  menopause,  653. 
Hygiene  of  marriage,  265. 
Hygiene,  rules  of,  125. 
Hymen,  63,  333. 
Hymen,  various  forms,  66,  67. 
Hyperaemia,  581. 
Hypersesthesia,    107,   178. 
Hyperplasia,  612. 
Hyrtl,  61,  213,  330,  446. 
Hysmans,  206. 
Hysteria,  154,  245. 

Icard,  203. 

Ideal  passion,  36. 

HI,  515. 

Impotence,  complete,   337. 

Impotence,  paralytic,   336. 

Impotence,  psychical,   335. 

Impotentia   concipiendi,  551. 

Impotentia  generandi,  551. 

Impulse,  sexual,    76,    123,    166,    168, 

169,  182,  190,  201. 
Impulse,  sexual,  inverted,  548. 
Impulse,  sexual,  perverted,  548. 
Impulse  toward   reproduction,   169. 
Inability  to  marry,  effects  of,  261. 
Inbreeding,  386,  486. 
Incapacity   for  inoculation  of  ovum, 

549- 


INDEX. 


677 


[References 

Incapacity  for  inoculation,  causes 
for,  552. 

Incest,    197. 

Incontinence,  278. 

Indifference,   sexual,   171. 

Individual  variations,   133. 

Infective    germs,   220. 

Infibulation,  416. 

Infidelity,    marital,   357. 

Inflammatory  processes,  87,  238. 

Influences  on  female  organism,  15. 

Injuries  in  parturition,  223. 

Injuries  in  parturition,  complica- 
tions, 224. 

Injuries  to  vagina,  331. 

Inner  tunic,  59. 

Insanity,  152,  249. 

Insomnia,   107. 

Instinct   for  preservation   of  species, 

2OI. 

Intensity  of  sexual  life,  26. 
Intercourse,  sexual,  at  early  age,  27. 
Intercourse,  sexual,  during    menstru- 
ation,  140. 
Intercourse,     sexual,     frequency     of, 

275- 

Intercourse,  sexual,  lack  of,  257. 
Intercourse,  sexual,  need  of,  281. 
Intercourse,  sexual,  promiscuous, 

301. 
Intercourse,  sexual,  restraint  in,  276, 

301. 

Intermenstrual  pain,  164. 
Intermenstrual  period,   140. 
Interval  between  periods,   132. 
Intestinal  meteorism,  46. 
Investigations,  anatomical,  446. 
Investigations,   experimental,  452. 
Investigations,    statistical,   422. 
Iridochoroiditis,  108. 
Irritable  weakness,  336. 
Irritation,  senile,  613. 
Islam,    129. 
Itching  sensation   in  genital   organs, 

46. 

Jackson,  494. 
Jacobi,   18. 


are  to  pages.] 
Jaffc,  235. 
Janovsky,    147. 
Jarowski,   112. 
Jealousy,   651. 
Jeamin,  208. 
Jeannel,  538. 
Jewesses,  45. 
Joachim,  45. 
Johannsen,  509. 
Johnstone,   138. 
Jolly,   186. 
Joseph,  147. 
Joubert,  42. 
Jung,  641. 
Junke,  450,  454. 
Justinian,  48. 
Juvenal,  192,  273,  392. 

Kahne,  89,   112. 

Kahlbaum,   101. 

Kahlden,   141. 

Kaltenbach,  292. 

Kapysa,  266. 

Katatonia,  103. 

Kehrer,  293,  299,  316,  417,  509,  513, 

521,   538. 

Kennedy,  337,  365. 
Keratitis,  108. 
Keppler,  566. 
Kerley,  165. 
Kerzmarsky,  499. 
Key,  Ellen,  201,  262. 
Kidney,   movable,    122. 
King,  364. 
Kirn,  103. 
Kiss,  285. 

Kiztnsch,  494,  603,  616. 
Klebs,  473,  490,  494,  507,  552. 
Kleimvaechter,    396,     406,    410,    556, 

563,  601,  618. 
Klinkosch-Hill,  494. 
Koblank,  364. 
Kocks,  417,  568. 
Koeberle,  182,  564. 
Koenig,  593. 
Koeroesi,  372,  375,  384. 
Kokkogam,  291. 
Koran,  294. 


INDEX. 


[References 
Kosstnann,  419. 
Kostewitsch,  630. 
Kowalewski,  102,  155,  647,  653. 
Krafft-Ebing,  77,   103,   155,   159,   176, 

184,    186,    189,    196,   258,   282,   349, 

355,  358,  403,  641,  647- 
Krause,  290,  348. 
Krausold,  195. 
Kretschky,  16. 
Krieger,  28,  31,  40,  43,  98,  130,   134, 

145,  482,  594,  603. 
Kristeller,  297. 
Kroenig,  257. 
Kroner,  335,  539. 
Krugenstein,  159. 
Kuehne,  116. 
Kulischer,  181. 
Kundrat,  89,  137,  142. 
Kussmaul,  81,  182,  189,  489,  494. 

Labalbary,  541. 

Labia,  212. 

Labial  hernia,  328. 

Laboring  classes,  27. 

Lacasella,  192. 

Lactation,    139,  403. 

Lafarque,  197. 

Lambert,    191. 

Lamy,  232. 

Landau,  143,  240,  566,  568. 

Lantier,  80. 

Larcher,  260. 

Lasarewitsch,  499. 

Lascivious    procedures,    195. 

Lateral  sacral  arteries,  14. 

Lauenstcin,  522. 

Laurent,  81. 

Laval,  146. 

Law,  109,  165. 

Lawrence,  161. 

Lawson  Tait,  102,  139,  564,  618,  637. 

Lebedinsky,  479. 

Lebert,  260,  616,  619. 

L*faJ,  45. 

L'Eclos,  573. 

Lecluyse,  567. 

L^,  474. 

'L*  Forf,  165,  339. 


are  to  pages.] 
Legoyt,  377. 

Legrand  du  Saulle,  159,  198. 
Legs,  paraesthesia  of,  107. 
Lehmann,  241. 

Leopold,  137,  141,  326,  528,  616. 
Leseurs,  318. 
Leube,   93. 
Leukart,  446. 
Lever,  466. 
Lez/t,  496. 
Levinstein,   473. 
L<?t/y,  419,  438,  531. 
Lewin,  478. 
L<?wy,  235. 
Leyden,  233,  252. 
Libido  sexualis,  641. 
Lichtenberg,  109. 
LiVfrfe,  393. 
Liegois,  166. 

Lur,  406,  558,  541,  559,  563. 
Limitation  of  offspring,  283. 
Linea  alba,  208. 
Linnaeus,   132. 
Lipomatosis,  93,  635. 
Lippich,  377. 
Liquor   folliculi,  59. 
Litschkuss,   499. 
Litsmann,  168,  296. 
Local  causes,  48. 
Local  disturbances,   145. 
Local  irritations,  177. 
Lotfc,  305. 
Loehlein,  556. 
Loewenfeld,   106,   173,   256,  308,  402, 

406. 

Loewenhardt,   137. 
Loewenthal,  304. 
Loewy,  22,  482. 
Lombard,  118. 
Lombroso,  46,  81,  159,  170,  186,  192, 

203,  210,  262,  301,  382. 
L0«a,  381. 
Lora in,  6l2. 
Lo^,  408,  502. 
Lout'j,  332. 
Love,  free,  305. 
Love  in  woman,   170,  285. 
Love,  Lesbian,   189,  415. 


INDEX. 


679 


[References 

Love  of  early  youth,  77. 
Love,  perfect,  263. 
Love,  platonic,  171. 
Lower,  538. 
Lucas,  494. 
Lucian,    192. 

Lumbar  enlargement,  226. 
Lumbar  pain,  46. 
I.umpe,  498. 
Luteaud,  320. 
Lutein  cells,  60. 
Luther,  168,  269,  385. 
Lycurgus,  272. 
Lymphatic  vascular  system,  15. 

MabUle,   155. 

Mackenzie,  109. 

Macnaughton  Jones,  161,  163. 

McClintock,  525. 

McDonald,  522. 

McDoivell,   564. 

McGillivray,  476. 

McLennan,  443. 

Magnan,  178,  198. 

Mahomedan  people,  62. 

Mahomet,  269. 

Mainlaender,    168. 

Mairet,  158. 

Male,  prepotency  of,  450. 

Malthus,  376,  389. 

Malthusian  League,  393. 

Mamma,  73,  75,  619. 

Mandl,   142,  235. 

Mania,  249,  650. 

Manipulations,   intrauterine,  238. 

Mantegassa,  23,  76,  170,  190,  193,  198, 

207,  213,  380,  405. 
Manus,  266,  385. 
Marasmus,   senile,  576. 
Marce,   155,  250. 
Marco   Clement,  2. 
Marholm,  205. 
Mariagalli,   17. 
Marilegoute,  434,  455. 
Markzellen,  89. 
Marotte,    102. 

Marriage,  at  what  age,  266. 
Marriage,  consanguineous,  387. 


are  to  pages.] 

Marriage,    immoral,  262. 

Marriage  of  near  kin,  267. 

Marriage,  premature,  473. 

Marsa,  364. 

Marsh,  597. 

Martial,   189. 

Martin,  80,   139,  299,  331,  337,  342, 

474,  512,  536. 
Martineu,  81,    190. 
Maschka,  61,  66,  72,   190,   195,  331, 

547- 

Masochism,  194. 

Masturbation,  88,  104,  124. 

Maternity,  200. 

Maturation,  140,  188. 

Matusch,  627,  646,  652. 

Maxwell,  613. 

Mayer,  31,  40,  45,  131,  297,  332,  384, 
478,  599,  603. 

Mayet,   382. 

Means  for  exciting  voluptuous  sen- 
sations, 361. 

Meinert,  90. 

Meissner,  365,  538,  606. 

Melancholia,   103,  257. 

Membrane,   uterine   mucous,   217. 

Menacme,  pathology  of,  218. 

Menacme,  physiology  of,  201. 

Menacme,  sexual  epoch  of,  200. 

Menarche,  37. 

Menarche  and  menopause,  595. 

Menarche,  pathology  of,  82. 

Menarche  praecox,  78,  82. 

Menarche  tardiva,  78,  82. 

Mende,  365. 

Mendes  de  Leon,  142,  235. 

Menge,  593. 

Menopause,  571. 

Menopause  and  race,  594. 

Menopause,  artificial,  580. 

Menopause,  changes  in,  582. 

Menopause  delayed,  600. 

Menopause,  pathology  of,  608. 

Menopause,  premature,   600. 

Menopause,  sudden,  600. 

Menopause,  time  of,  593. 

Menorrhagia,  86,  160,  608. 

Menses,  suppression  of,  233. 


68o 


INDEX. 


[References 

Mensinga,  406,  411. 

Menstrual  blood,  129,  130. 

Menstrual  cycle,   19. 

Menstrual  psychoses,   193. 

Menstrual  stimulus,   103. 

Menstrual  style,  148. 

Menstruation,   124. 

Menstruation,  anomalies  of,  83. 

Menstruation  and  age,  32,  38. 

Menstruation  and  climate,  32. 

Menstruation    and    nationality,    32. 

Menstruation,  beginning  of,  30. 

Menstruation,  bloodless,   578. 

Menstruation,  cardiac  activity  dur- 
ing, 143- 

Menstruation,  cessation  of,  576. 

Menstruation,  disorders    during,    144. 

Menstruation,  disturbances  of,  219. 

Menstruation,  first  appearance,  45, 
82. 

Menstruation,  irregular,   134. 

Menstruation,  late,  483. 

Menstruation,  pathology  of,   143. 

Menstruation,  praecox,  79. 

Menstruation,  regular  type   of,   134, 

Menstruation,  remittent,  135. 

Menstruation,  vicarious,    164. 

Mental   disturbances,  145,  161. 

Mental   stimuli,  84. 

Merrier,  118. 

Merson,  653. 

Messalina,    185. 

Metabolic  balance,  94. 

Metabolism,  19,  635. 

Metamorphosis,   retrogressive,   584. 

Metritis,  chronic,  6n. 

Metritis,  virginal,  232. 

Metrorrhagia,  86. 

Mctschnikoff,  32. 

Meyerhofer,  300,  304,  446. 

Mich  I,  525. 

Michelet,  6,  273. 

Micklucho-Mackay,  415,  476,  541,  564 

Mill,  393- 

Miller,   108. 

Mind,  disturbances  of,  226. 

Minor  troubles,  226. 

Misuse  of  medical  science,  395. 


are  to  pages.) 

Moebius,  268. 

Moericke,   141. 

Moist  appearance,  51. 

Mo  lit  or,  So. 

Moll,  175,  189,  194,  198. 

Mons  veneris,  210. 

Montesquieu,  378,  538. 

Montgomery,  80. 

Moor  en,  108,  160. 

Moraglia,   194. 

Moral  demand,  36. 

Morality,  sexual,  36. 

Morbus  virgineus,  92. 

Moreau,  122,  332,  573. 

Morgagni,  472. 

Morityel,  484. 

Morning  sickness,  231. 

Morphological    elements    of    semen, 

310. 

Mortality  of  married  men,  174. 
Mortality  of  married  women,  218. 
Morton,  407,  466. 
Mosaic  law,  129,  270. 
Moser,  438. 

Motherhood,  dread  of,  201. 
Mother's  supervision,  120. 
Moulin,  478. 
Mourange,  612. 
Mucus,  alkaline  cervical,  133. 
Mueller,   168,  233,  300,  320,  332,  475, 

499,  528,  623. 
Munde,  515,  612. 
Murmurs,   systolic,   149. 
Murphy,  334. 
Museums,  120. 
Mussy,  292,  641. 
Myoma,  240. 

Naegcle,  137. 
Nagel,  60. 
Napier,  161. 
Nathusius,  379. 
Natural   frigidity,   172. 
Natural  instincts,  I2O. 
Nausea,   107. 
Neefe,  43a 
Nega,  494. 
Negri,   17. 


INDEX. 


681 


[References 

Negroni,  474. 

Neisser,  537,  554. 

Nerves,  10. 

Nervous  disturbances,    150,   161,  248. 

Nervous  diseases,  243,  244,  637. 

Nervous  irritability,  145. 

Nervous  system,  99. 

Ncudoerjer,  108. 

Neugebauer,  407,  528. 

Neumann,  245. 

Neuralgia,   151. 

Neurasthenia,    107. 

Neurasthenia,  sexual,  123. 

Neuroses,  149,  225. 

Neusser,  17,  89. 

Nieden,  365. 

Nietschke,  202. 

Noble,  492. 

Noegerath,  512,   531,  534,  537. 

Noinot,  423. 

No  or  den,  21,  90. 

Nordau,  399. 

Nothnagcl,  113. 

Novels,   120. 

Nussbaum,  449,  474. 

Nutrition   and   genesis,  376. 

Nymphomania,    184. 

Obesity,  23,  92,  479,  636. 

Obermeier,  165. 

Obturator,  412. 

Ocular  trouble,  108. 

Oceania,  43. 

Odebrccht,    119. 

Ochlschlaeger,  304. 

Oehlshausen,  249,  343,  474,  476,  509, 
523,  537,  56o. 

Ocstcrlen,  122,  331,  422. 

Official  examination  before  mar- 
riage, 265. 

Old  maids,  644. 

Olfactory  sense,   109. 

Oligozoospermia,  316. 

Onanism,   199,  404. 

Onanism,  mechanical,  106. 

Onanism,  mental,   106. 

Onanism,  peripheral,    106. 

Onanism,  psychical,  351. 


are  to  pages.] 

Only-child-sterility,  464, 

Oopherectomy,  139,  475. 

Operative  measures,  415. 

Oppenheimer,  538. 

Organ  of  hearing,  148. 

Organ  of  vision,  148. 

Ormerod,  494. 

Ostium  uterinum  tubse,  56. 

Ott,  18,  20,  146. 

Otto,  328. 

Outer  tunic,  59. 

Ovals,  413. 

Ovarian  tenderness,  IOO. 

Ovaries,  216,  471,  473,  474. 

Ovaries,   anatomical   alterations,   583. 

Ovaries,  atrophy  of,  583. 

Ovaries,  changes  in,  8. 

Ovaries,  diseases  of,  489. 

Ovaries,   extirpation   of,   564. 

Overstrain,  intellectual,   120. 

Ovid,   213. 

Ovulation,  136,  470. 

Ovum,    discharge   of,    136,    304,    306, 

307. 
Owen,  393. 

Paget,  619. 

Pagliani,  46. 

Pajot,  293,  506,  527. 

Pajot-Negrier,  135. 

Palmay,    549. 

Palpitation,  46,  95,  97,   107. 

Panecki,  234. 

Papa,  194. 

Paranoia,  152. 

Pare,  285. 

Parent-Duchatelet,  81,   193,  477,  538. 

Parsons,  165. 

Pathological    conditions    in    woman's 

life,  599. 
Patriarchical  relationship  of  woman, 

5- 

Patru,  6lO. 
Pauli,  147. 
Pean,  182. 
Pelman,  155. 
Pelvic  viscera,  9. 
Penis  captivus,  340. 


INDEX. 


[References 

Percy,  314- 

Period  of  sexual  pleasure,  350. 

Peripheral  nerves,  16. 

Peristalsis,  107,  229. 

Perversion,  sexual,  195,  360. 

Pessaries,  406,  411. 

Petiteau,  165. 

Peyer,  293. 

Pi  off,  190: 

Pfannenstiel,  59. 

Pfannkuch,  369,  559. 

Pfau,  498. 

Pflueger,  136,  475,  546. 

Philo-Indiens,    156. 

Physical   disturbances,   153. 

Physical  exercise,  113. 

Physician's    duty    to    enlighten    girls, 

125- 

Picture  galleries,  120. 
Pigelot,  407. 
Pigmentation,   161. 
P 'incus,  419. 
Pisciculture,  458. 
Place,  393. 
Plato,  265,  391,  666. 
Pleasurable  sensations,  177. 
Plenk,  333. 
Plicae  palmetae,   29$. 
Pliny,  185,  273,  463. 
Plan,  38,  46,  62,  81,  185,  214,  291,  308, 

361,  416,  433,  446,  476,  545. 
Plutarch,  190,  302,  420. 
Plyette,  79,  165. 
Pollutions,  352. 
Polypus,  510,  590. 
Pomeroy,  276,  414. 
Porro's  operation,  567. 
Portio  vaginalis,  503. 
Position,   different   modes   of,  291. 
Potain,  150,  628. 
Potentia  coeundi,  309. 
Potentia  generandi,  309. 
Pouchet,    136. 
Power,  1 08. 
Pozzi,  343. 

Pregnancy,  139,  245,  247. 
Preventive   measures,    255,   292,    388, 

399,  410. 


are  to  pages.] 

Prcvost,  7. 

Prima  nox,  302. 

Primitive  conditions   of   society,  5. 

Prior,  365. 

Prochnowick,  559. 

Prochosonick,  538.  . 

Profluvium   seminis,  358. 

Prohibited  degrees,  268. 

Pro-nucleus,     female,  305. 

Pro-nucleus,  male,  305. 

Prostitution,  195,  262. 

Pruritus,  vaginal,   107. 

Pruritus,  vulvae,    107,  634. 

Pseudo-narcotism,  626,  638. 

Psychical  influences,   17. 

Psychical  manifestations,  18. 

Psycho-neuroses,  23. 

Psychopathia  sexualis,  184,  257. 

Psychopathic  states,   152. 

Psychoses,   155. 

Puberty,  37,  200. 

Pudendum,   female,  204. 

Pudic  nerve,  in,  348. 

Puech,  29,  109,  165,  182,  478,  597,  603. 

Pulse,  94,  96,    144. 

Pye-Smith,  100. 

Pyrosis,   107,  228. 

Quain,  166,  472,  494,  629. 
Quetelet,  366,  379. 

Rabba,  129. 

Rabbi  Akita,  129. 

Rabbi  d'Azai,  129. 

Rabbi   Jose,    129. 

Rabbi  Joshua,  266. 

Rabbinowits,   129. 

Rabutcau,   18,   19. 

Race,    38. 

Rachitis,    117. 

Raciborski,  26,  122,  247,  258,  260,  268, 

274,  399- 

Railway   accidents,  84. 
Rape,  295. 
Raschi,    129. 
Ratgen,   165. 
Ratios     between     male     and     female 

births,  422. 


INDEX. 


683 


[References 
Ravn,  43. 
Rayer,  633. 

Recreation,  domestic,   121. 
Reflex  disturbances,  230. 
Regeneration,   post-menstrual,    143. 
Regnier,  163. 
Regulation     of     sexual     intercourse, 

269. 

Reichert,  137. 
Rcine,  18,  163. 
Relations   of   healthy  and   unhealthy 

female  organs  to   other  organs  of 

the  body,  25. 
Renaudin,  482,  494. 
Reproductive  organs  of  girl  of  ten, 

53- 
Reproductive    organs    of    new    born, 

52. 

Reproductive  organs  of  virgin,  55. 
Respiratory  organs,  107,  146,  254, 
Rest  cure,  113. 
Retching,  107. 
Retroflexion,  88,  230. 
Reuter-Gabriele,  201. 
Reyher,  414. 
Rheinstein,   143. 
Rhythmical  variations,  20. 
Ribbing,  26,    122,  247,   258,  268,   274, 

399- 

Ricardi,  194,  452. 
Richard,  265. 
Richarz,  451. 
Richter,  22. 
Ricord,  408. 
Riecke,  13. 
Ricdel,  403,  544. 
Kiese,  438. 

Rights  of  physical  love,  203. 
Rights  of  women,  173. 
Ritchie,  482. 
Roberts,  564. 
Rochard,  466. 
Rodbertus,   393. 
Rodriguez,  480. 
Rodzewitsch,  365,  482. 
Roehrig,  15,  525. 
Rogival,  618. 
Rokitansky,  489,  494,  603. 


are  to  pages.] 
Romberg,  642. 
Rooseveldt,  394. 
Rosen,  478. 
Rosenbach,  252. 
Rosenthal,  352. 
Rosenstadt,  180. 
Rosin,   1 1 6. 
7?o^t,  109,  317,  332. 
Rosthorn,   12,  214,  492. 
Roth,  211,  452. 
Roubaud,  287,  289,  362. 
Rouget,  296. 
Rousseau,   103,  124,  213. 
Routh,  181. 
Rouvier,  42. 
Rueder,  612. 
Ruettel,  364. 
Rugae,   216. 
^«£<^  475,  522. 
Runge,  121,  176,  221,  261. 
#w.yA,  365. 
Russ,  loo. 
Rut,  136,  139. 

Sacher-Masoch,  193. 
Sacrache,  46. 
Sadism,    194, 

Sadler,  366,  369,  377,  422,  430. 
.Saenger,  119,  396,  492,  512,  537. 
Saexinger,  494,  616. 
5V.  Hilaire,  434. 
5V.  Prospere,  171. 
Salmon,  21. 
Sand,  262. 
Sappho,  190. 
Saischoma,  499. 
Scanzoni,  72,  275,  326,  474,  517,  523, 

597,  604,  616,  619. 
Schaefer,  155. 
S chat 2,   475. 
Schauenstein,    191. 

Schauta,  144,  147,  162,  245,  260,  490. 
Schenk,  458,  486. 
Schichareff,  18,  20. 
Schiller,  271. 
Schlager,  154,  645,  653. 
Schlesinger,  141. 
Sell  ma  fuss,  166,  182. 


684 


INDEX. 


[References  are  to  pages.] 


Schmidt,  29,  365. 

Schnuerleber,  122. 

Schnuerthorax,  90. 

Schoeltz,  116. 

Schoenfeld,  330. 

Schonlein,  108. 

Schopenhauer,  168,  202. 

Schorler,  559. 

Schottlaender,  60. 

Schroder,  19,   126,   146. 

Schreiner,  312. 

Schroedcr,    155,    341,    521,    525,    538, 

564- 

Schubert,    116. 
Schuler,  153,   186,  653. 
Schuermayer,  197. 
Schultse,  210,  448,  556. 
Schwartz,  536. 
Schwing,  147,  365. 
Scoff,  614. 
Scrofula,   117,  484. 
Seaside,    117. 
Seasonal  variations,  180. 
Seborrhcea,   110,  118. 
Sebum,  no,  118. 
See,  100. 

Seeligman,  165,  466,  535. 
Segmentation   sphere,  306. 
Seller,  92. 
Self-deception,   574. 
Semper,  450. 
Senator,   146. 
Senescence,  572. 
Sensation   of    fulness   in   hypogastric 

region,  46. 

Senses,  organs  of,  108,  145,  250. 
Sensibility,  sexual,  in  women,  542. 
Sergi,  170. 

Sex  combination,  427. 
Sex  relations,  35. 
Sex,  third,  201. 
Sexual  abuses,  258. 
Sexual   impulse,    179. 
Sexual  life,    central    perceptions    of, 

177- 

Sexual  life,  development  of,   176. 
Sexual  needs,  33. 
Sexual  neurasthenia,  199. 


Sexual  satisfaction,  177. 

Shakespeare,  277. 

Sheldon,  612. 

Sheltered  life,  212. 

Sickel,  438. 

Signs,  prodromal,  129. 

Siebold,  438. 

Simon,   130,  527. 

Simpson,  218,  465,  487,  603,  618. 

Sims,  297,  314,  318,  365,  466,  513,  521. 

Sinety,  141. 

Sinteinma,  136. 

Skene,  612. 

Skin,  diseases  of,  146,  632. 

Skin,  eruptions  of,  146. 

Skopski,   184. 

Slavjanski,  473. 

Sleep,  115. 

Sloan,   108. 

Smegma,  51,  529. 

Soaps,    118. 

Social  circumstances,  599. 

Social  significance  of  sexual  life,  33. 

Socrates,  269. 

Sodomy,  190. 

Solanieff,   556. 

Solon,  269,  273. 

Sommerus,  482. 

Song  of  Solomon,  23. 

Soranus,  308,  381,  420,  463,  502. 

Spaeth,  438. 

Spallanzan,  317. 

Spartan  custom,  272. 

Spasms,  clonic,  102. 

Spasms,  tonic,    102. 

Spencer  Wells,  182,  376,  466,  485. 

Spermatozoa,  304,  306,  310. 

Spiegelberg,  475,  515,  560. 

Spietschka,  no,  118,  209. 

Stadion,   193. 

Stael,  3. 

Stark,  482. 

Starkweather,  451. 

Stays,  tight,  97. 

Steatopyga,  573. 

Steglehner,  528. 

Stein,   202. 

Steinbow,  203. 


INDEX. 


685 


[References 
Steiner,  100. 
Stenocardia,  98. 
Stepanow,  109. 
Stephenson,  85. 
Sterility,  absolute,  540,  569. 
Sterility,  artificial,  413,  462,  464,  468, 

484. 

Sterility,  one-child,  561. 
Sterility,  operative,  563. 
Sterility,  relative,  540,  569. 
Sterility,  varieties   of,   470,    569,    570. 
Stevens,  522. 
Stieda,  91,  384. 
Stiehl,  124. 
Stille,  406. 
Stiller,   147. 
Stimulation,  local,  237. 
Stimulation,  mechanical,    15. 
Stimulation,  thermic,  15. 
Stomach,  ulcer  of,  107. 
Storer,  414. 
Strabo,  415,   564. 
Strahan,  386. 

Strassmann,  16,  138,  140,  143,  241. 
Struts,  24,  212. 
Striae,   209. 
Strindberg,  206. 
Strogamoff,  593. 
Sudden  frights,  84. 
Suesserot,  525. 
Suicide,   174. 

Suppression  of  menses,  158. 
Susruta,  48,  129,  307,  420,  463. 
Swieten,  333. 
Swift,  441. 

Sympathetic  action,  549. 
Sympathetic  nervous  system,  237. 
Syncope,   150. 
Synkits,  482. 
Szukits,  28,  131,  134. 

Tachycardia,  23,  345. 

Tain,  407. 

Talmud,  129,  276,  292,  294,  307. 

Talquist,   365,   383. 

Tardicu,  190,  195. 

Tarnowskaya,  382. 

Tarnowsky,  262. 


are  to  pages.] 

Tassenbrock,  142. 

Taste,  acid,    107. 

Taste,  pasty,  107. 

Taste,  perverse,  107. 

Tauffer,  166,  496,  499. 

Taxil,   192. 

Taylor,  364,   482. 

Tea,    121. 

Tenderness  of  breasts,  46. 

Tetany,  247. 

Theaters,   120. 

Theiihaber,  235,  609. 

Theopold,  543. 

Thiery,  452. 

Thomas,  413. 

Thompson,  334,  404,  406. 

Thorn,  602. 

Thyroid,   108. 

Tilt,  29,  31,  43,  135,  518,  582,  594,  600, 

626,  629,  631,  634,  666. 
Timan,  325. 
Tissier,  183. 
Tissot,  102. 
Toldt,  215. 

Tolstoi,  34,  206,  397,  40!. 
Tonsils,  hypertrophy  of,   107. 
Touchon,  453. 
Tousenel,  443. 
Towels,  sanitary,  125. 
Towers-Smith,  480. 
Traugott,  116. 
Travels,  121. 
Tribadism,  190. 
Troggler,    187. 
Troubles,  domestic,  219. 
Tschowuloff,  382. 
Tuberculosis,   259. 
Tuke,  155. 

Tumors  of  rectum,  334. 
Tunica  propria,  60. 
Tussenbeck,  235. 
Two-children-system,  384. 
Tyler-Smith,  522. 

Ultzmann,  287,  312. 
Uncle,  194. 
Underwear,  122. 
Undulatory  movement,   18. 


686 


INDEX. 


[References 

Uneasy  sensations,  46. 
Unhappy  marriages,  190. 
Union  of  Social   Harmony,  393. 
Upbringing,   domestic,    120. 
Upjohn,  449. 
Urinary  organs,  146. 
Urine,  retention  of,   126. 
Urnings,  197. 
Uterine  annexa,  566. 
Uteromania,  184. 

Uterus,   91,  214,   297,  494,  499,   500, 
515,  523,  558,  590,  614,  617. 

Vacher,  383. 

Vagina,  216,  526. 

Vaginal   stricture,  346. 

Vaginisms,  335,  337,  341,  345. 

Vaginodynia,  343. 

Valenta,  406. 

Varge,  333- 

Vascular  system,   13. 

Vasomotor   disturbances,    104,    151. 

Vedeler,  521. 

Veins,  13. 

Veil,  60,  87,  308,  327,  342. 

Velpeau,  619. 

Venus  apparatus,  412. 

Venus  powder,  412. 

Vera,  35. 

Veraism,  263. 

Vertigo,  46,   154. 

V vault,  1 1 8. 

Villerme,  577,  379. 

Viraginity,   190. 

Virchow,  86,  91,  208,  379,  489. 

Virey,  132,  328,  545,  595. 

Virginity,  moral,  123. 

Visceral   neuralgia,  640. 

Vitreous  body,  108. 

Vogel,  130. 

Voigt,  165. 

Voltaire,  285. 

Voluptuous  sensations,  203. 

Vomiting,  107,  230. 

Vorst,  394. 

Vulva,  526. 

Wald,  191. 

Waldeyer,  58,  60,  605. 


are  to  pages.] 
Wallace,  400. 
Walter,  607. 

Wappaeus,  379,  423,  435. 
Waterbrash,  228. 
Waters,  natural,  116. 
Waters,  mineral,   116. 
Watson,   165. 
Weakly   women,  28. 
Weight  at  age  of  puberty,  47. 
Weinbrunn,   332. 
Weinhold,  416. 
Weiss,  333. 
Wendelcr,  591. 
Werne,  416. 
Wernick,  296. 
West,  474,  525. 
Westphal,  142,  158,  189,  195. 
Weybsbart,  210. 
Whitehead,  369. 
Wilhelm,  147. 
Wilkins,  445. 
Willbrand,   193. 
Wille,  157,  407. 
Williams,   137. 
Wilson,  635. 
Windmueller,  165. 
Windscheidt,  150,  243,  247,  627,  640, 

642. 
Winkel,   128,  342,  474,  509,  523,  527, 

558. 

Winter,  84. 
Winterhalter,  138. 
Withrow,   165. 
Woman,  influence  of,  206. 
Women  writers,  34. 
Wyder,  304,  332. 

Yamagiron,  217. 
Young,  482. 

Zarathnstra,  202. 
Zeiss,   331. 
Zeissl,  478,  535. 
Ziehl,  496. 
Ziemssen,   526. 
Zo/a,  193. 
Zoroaster,  269. 
Ziinaikornusta.r.  210. 
Zweifel,  72,  528. 


University  of  California 

SOUTHERN  REGIONAL  LIBRARY  FACILITY 

405  Hilgard  Avenue,  Los  Angeles,  CA  90024-1388 

Return  this  material  to  the  library 

from  which  it  was  borrowed. 


tU. 


MAY  1  8  1994 


ooo      " 


2549" 


WP100 

K6ls 

1910 


Kisch,  Enoch  H 

Sexual  life  of  woman. 


WP100 

K6ls 

1910 


Kisch,  Enoch  H 

Sexual  life  of  woman. 


MEDICAL  SCIENCES  LIBRARY 

UNIVERSITY  OF  CALIFORNIA,  IRVINE 

IRVINE,  CALIFORNIA  92664 


•••• 


